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TANK TAN ftERMIT APPLICATION INFORM�ON COMPLETE A SEP,AIWE FORM WITH THE FOLLOWING INFORMATI OR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ' a ONE ITEM ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 2 INTERIM PERMIT ❑A AMENDEOPERMITEl7 PERMANENTLY CLO FACILITY/SITE NAME WHERE TANK IS INSTALLED- ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY FARM TANK-YES❑ NO A OWNERS TANK IDM C. YEAR INSTALLED �� R. MANUFACTURED By. D. TANK CAPACITY IN GALLONS: 11. TANK C TENTS IF(Ai),IS ARKED,C MPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM O. A. A MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED J ❑ O CHEMICAL PRODUCT ❑ A OIL DIESEL ❑5 HAZARDOUS ❑ W EMPTY ❑95 UNKNOWN ❑ I PRODUCT ❑N GASAHOL E] 6 5 JET FUEL ❑ N AVIATION GAS D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0.BELOWI HAZARDOUS SUBSTANCE STORED 6 C.A.S.N x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 D OAS p A TYPE OF ❑ 1 LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM ❑2 SINGLETHER LED ❑ /SECONDARYODNiAINMENT ❑99 OTHER El 95 UWNOWN B. TANK ❑ 1 STEEUIRON ❑2 STAIWESSSTEEL 3 FIBERGLASS ❑1 STEEL CIAO W/FIBE11GlAS$RENFOpCFO"TICMATERIAL ❑ 5�•�E ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ElB I00%MEIFMII ❑9 BRONZE 10 GALVANIZEDSTEEI 95 UNKNOWN ❑99 OTHER IX COMPATIBLE FRP C. INTERIOR ❑ I RUBBER LINED 2 ALKYDLINING LINING ❑ 5 GLASS LINING / ❑3 EPDXY LINING A FHENOLICUMNG ❑ MINED 95 UNKWM ❑ IS LINING MATERIAL COMPATIBLE WITH 10 METHANOL, El YES ED NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP 2 TAROK ALT ❑ 3VINYlWMP PROTECTION ❑5 CA,—PROTECTION ❑9I ONE 95 UNKNOWN ❑4 RBENGIASSREINFORCFDRASTIC ❑ ❑99 OTHER IV- PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U I SINGLE WALLED A A U 99 OTHER U 4 DOUBLE WAILED A U J LINED TRENCH A U I STEEL/IRON A U 95 UNKNOWN A U 99 OTHER C. MATERIAL A U ' STAINLESS STEEL A U ] POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 5 ALUMINUM A U 6 CONCRETE A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 7 STEEL CLAP W/FRP A U S 100%METHANOL COMPATIBLE FRP A U THER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDA A PRIMARY LEAK DETECTION SYSTEM MUST P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I EL TRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNK WN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s gs OTHER___ _ I ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED QUANTITY Of SUBSTgNCF REMAINING IN 3 WAS TANK FILLED WITH GALLONS NDER PEINERT MATERIAL' E]YES Ej NO� THIS FORM HAS BEEN COMPLETED UNALTY OF PERJURY,AND TO THE BEST OF MY SIGNA TKNOWLED (PRINTED GE,IS TRUE AND CORRECT APPLICANL'S NAME ,f URF O!5 EI•. ( 1 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY N FACILITY IO N II( ILII - 7 7C /T/AYN�K ID M CURRENT LOCAL AGENCY FACILITY Cn 716 /�U i /q APP�V�BY NAME PHONE N WITH AREA CODE PERMIT NUMBER VI' / -'-- o(�/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE _-- --- -- - --- CNECK N PERMIT AMOUNT - - SUgGNApGEAYT. RECEIPT/ BY: --—M 8(3.7 881 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FOR M 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED "- - - • DATA PROCESSING COPY •