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- __. ...... ... a_E 1111 LANIA, MARK ONLY ❑ I NEW PERMIT ❑ J RENEWAL PERMIT ❑5 CHANCE OF INFORMATION ❑ 1 PERMANENTLY CLOSER TANK ONE ITEM F-12 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED Y� FACILITY/SITE NAME WHERE TANK IS INSTALLED: /Z S.1274 AVAW FARM TANK-YES NO -7 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN—SO SPECIFY to A OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: .L� 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM BC ❑ 1 UNLEADED 2 LEADED ❑ D DIESEL N O CHEMICAL PRODUCT ❑ 1 OIL ❑ 1 PRODUCT ❑ E GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ M EMPTY LA 95 UNKNOWN ❑ 2 WASTE ❑ 2 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME 01 HAZARDOUS SUBSTANCE STORED A C A .N C.A.S.N Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,S.C.A D A TYPE OF ❑ I DOUBLE WALLED ❑ 0 SINGLE WALLED NIM E%IERKIR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑A SECONOANNCONTMMLAENI ❑99 OTHER _ ❑ I SEEUIRDN ❑2 STAINLESSSTEEI ❑ 0 FIBERGLASS ❑1 STEELCIADWUfwfwAA55RENfORCEDRA9DC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIN F-1i ALUMINUM ❑e 100%METHANOL COMPATIBLE FW MATERIAL ❑ 9 BRONZE ❑ 10 GAIVANIZEDSTEb 1:1 95UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBERLIMU) ❑2 ALKYOUNING ❑ 9 FPOKY LINING ❑1 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 1 ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 0YES 0N ❑99 OTHER D. CORROSION ❑ I POLYETWEM WRAP ❑2 TAR OH ASPHUI ❑ )VINYL WRAP ❑A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NON[ ❑ 95I NKNOWN ❑99 OTHER—___ _ IV. PIPING INFORMATION CIRCLE A If ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U ? PRESSIARf A U 9 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLEO A U 9 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U ' STAINI(Fu'0t FI A U ) POLYVINYLCHLORIDFFPVCI A U A FIBERGLASSPME C. MATERIAL A U S ALUMINUI A U 6 CONCRF II A U ' STEEL CIAO W/GRP A U R IB06 METHANOL COMPATIBLE FNP A U 4 GAIVANIIEIISILEI A U JS UNKNOWN A U 'N OILIER V. LEAK DETECTION SYSTEM CIRCLE P FORPRIMARY OR S FOR SECONDARY.APRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 21NVENIORYRECONCIIIAIIOH P S I VADU:if W(.IIS P S A ELECIRONICOONITOR P S S GROUNOWAIFRMONIIORING WELLS P S fi PRECISION TESTING P S I PRESSURE TESTING P S 91 NONI P S 95 UNKNOWN P S "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I FSTIMATFD DATE USI U9ED IMO/MRI - - -.T- -7 TSbA.ci nww,,IHY(II ' t WAS TANK EILLFOWIIIH--�------- 1111'0 AN''F RI MAINING IN GALLONSI INERI MATERIALF] YES NO THIS FORM HAS BEEN COMPLETED UNOCR IT NAL IV a 01-1002Y.ANI) TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORf9FC 1 APPUCAN I C NAI.IF 1"IFN I I A%SIIRNA 11111 DAS F I Ib J LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY 10• � APPROVED BY NAPE PHONE E WITH AREA CODE PERMIT NUMBER PERMITAPPROVALDATE PERMIT E%PUPATION DATE --- — CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM BID.T-m) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FO R M 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY -777.7=. ,...