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TANK (/ TANWRMIT APPLICATION INFORMISON ' <br /> COMPLETE A SEPAWE FORM WITH THE FOLLOWING FORMATI OR EACH TANK. id <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION7 PERMANENTwo <br /> ONE ITEM ❑ 2 INTERIMPERMIT A AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE B TANK REMOV <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Cv /g L FARM TANK-YES <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Ip <br /> A. OWNERS TANK IDM B. MANUFWeED <br /> C. YEAR INSTALLED �f 0. TANK C /11. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOTIT D.A. i MOTOR VEHICLE FUEL 2 PETROLEUM BEj3 DIESEL3 CHEMICAL PRODUCT A OIL ElI PRODUCT5 JET FUEL D 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY [::]95 UNKNOWN 2 WASTE 7 METHANOL [:]99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.K CAS.N. <br /> KIII. TANK CONSTRU N MARK ONE ITEM ONLY IN BOK A,8,C.A D <br /> A TYPE OF ❑ I LE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER �95 UNKNOWN <br /> SYSTEM 2 SI RUED 1 SECONDARY CONTAINMENT gg OTHER <br /> I STEEUIRON 2 STAINLESSSTEEL E] 3 FIBERGLASS E]4 STEEL aAD W7RBEROASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE B POLYVINYL CHLORIOF � 7 ALUMINUM 8 1 OL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 0 95 UNKNOWN OTHER <br /> I RUBBER LINED 0 2 ALKYDUNING 3 EPDXY LINING / NOLICUNING <br /> C. INTERIOR 1 I <br /> LINING ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWR <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' EjYES NO 99 OTHER <br /> -ffj0. CORROSION I POLYETMIENE WRAP 2 TAR OR ASPHALT El 3 L WRAP 1 FNIERGlA55 REINFOACEO RASTIC <br /> PROTECTION 5 CATHODIC PR07ECTtON 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATON CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A jUj I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESS STEEL. A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FAP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> S VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATFRMONITORING WELLS <br /> 6 PRECISION TESTING P S 7 PRESSURE TESTING P 5 91 NONE P S 95 UNKNOWN P S MOTHER <br /> �I 1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH <br /> SUBSIANCE REMAINING IN ALLON$ INERT MATERIAL+ ❑YES ONO <br /> G , <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRIMED n SIf.NA1LIRF I Oq E I; ' <br /> 1 � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCY M FACILITY ID M TANKION <br /> c o_ 6 7 <br /> CURRENT LOCAL AGENCY FACILITY 10M APPROVED BY NAME PHONE N WITH AREA CODE <br /> \JAA4N1ST <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 7 <br /> CHECK/ PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT/ BY: <br /> FORM B 0 7 BB1 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> . DATA PROCESSING COPY • <br />