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An11K I ANK PtRMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORM • FOR EACH TANK- a MARK ONLY •� •' , ;, 1 EW PERMIT 7 RENEWAL PERMIT ONE ITEM �5 CHANGE OF INFORMATION ]PERMANENTLY CLOSED TANK TERIM PERMIT A AMENOEOPERMIT6 TEMPORARY TANK CLOSURE B TANK REMOVEDFACILITY/81TE NAME WHTANK I8 IN I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN— `/ , I FARMTANK-TESD NO _ S�BMA A OWNERS TANK 10 M �/ O ACTURED BY: C. YEAR INSTALLED / r D. TANK CAPACITY IN GALLONS: I II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL 2 PETROLEUM A J CHEMICALPROOUCT A OIL B C' ❑ 1 UNLEADED 2 LEADED 7 DIESEL 5 HAZARDOUS BO EMPTY 95 UNKNOWN E PRODUCT A GASAHOL 5 JET FUEL N 6 AVIATION GAS D. IF NOT MOTOR VEHICLE FUEL.ENTER NgME OF 2 WASTE � 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) HAZARDOUS SUBSTANCE STORED d C.A.S.M .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A S.C.A D CA.S.N A TYPE OF ❑ I DOUBLE WALLED L_j J SINGLE WALLED WITH EXTERIOR LINER SYSTEM SINGLE WALLED 0 E SECONDARY CONTAINMENT ❑95 UNKNOWN W OTHER I STEEL/IRON 0 2 STAINLESS STEEL 7 FIBERGLASS I STEEL CLAD W/fIBEROIAS$REIFEOfiCED"TIC B MATTERIAL 5 CONCAVE ❑B POLYVINYL CHLORIDE 7 ALUMINUM A'00%METHANOL COMPATIBLE FRP 9 BRONZE IO GALVANIZED STEEL 095 UNKNOWN 99 OTHER C. INTERIOR 1 RUBBERLINED 2 ALKYD LINING " 7 EPDXY LINING N PBENCLIC LINING LINING ❑ 5 GLASS LINING 06 UNLINED ! ! 95 IS LINING MATERIAL COMPATIBLE WITH LOOM METHANOL, L�J "UNKNOWN YES �NO �99 OTHER D. CORROSION I POLYETHLENE WRAP 0 2 TARORASPKgl PROTECTION0 7 VINYL WRAP 0 I F16ERGlASS REINFORCED PLASTIC 5 CATFIOpIC PROTECTION0 91 NONE �95 UNKNOWN El g9 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U ' SUCTION A U 2 PRESSURE A U ] CNAVIIY B. CONSTRUCTION A ;u/ I SINGLE wnuEDA �— A U 59 LATHER 2 DOUBLE WALLED A U J LINED TRENCH A LA I STEEL/IRON � A U 95 UNKNOWN A U 99 OTHER C. MATERIAL A U ? STAINLESS SIEEI A U ] POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 5 ALUMINUM A U 6 CONCRETE A U 9 GALVANIZED A 1 STEEL CLAD W/FNP LEOSTLEL ACU 95 UNKNOWN A U A U BIDDM METHANOL COMPATIBLE FHP U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P EOR PRIMARY,OR $ FOP SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ( P 5 I VISUAL CHECK P2 INVENTORYR_IS P ISECONCILIATION P S I VADOSE WELLS P S 6 PRECISION TESTING P S I PRESSURE TESTING ELECTRONIC MONITOfl P 5 5 GROUND WATERMONITORING WELLS P 5 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ° S OTHER I ESTIMATED DATE LAST USED IMOJYH ESTIMATED DUAN T I IY Of SUBSIANCE REMAINING IN WAS TANK FILLED WI1M - GALLONS INERT MATERIAL' E]YES D NO� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT AYPLICAN T'S NAIAE(1'HINI f D 6$If1Nn I UIp 01♦ E!•. LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N -- AGENCY N FACILITY ID N TANK ID N ` �, �` CURRENT LOCAL AGENCY FACILITY ION '- z-/v,-;r//v //G APPROVED BY NAME _ I PHONE N WITH AREA CODE PERMIT NUMBER - - - - PERMITAPPROVALDATE PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGE AAT. FEE CODE RECEIPTS BY: FORM B IJ 2-88) THIS FORM MUST BE ACCOMPANIED BY A FACILTTY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORY'A' HAS BEEN FILED I --` - DATA PROCESSING COPY hii:.:till:,�l'?4::a:Re^A:1�3•IGib�A2DPJ1Y3l1RRM`.F:Liuuc:.K • ' ' - • •1