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TANK TANKRMIT APPLICATION INFORMA N �, COMPLETE A SEPA FORM WITH THE FOLLOWING INFORMATIOMR EACH T NK. a MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLO ONE ITEM ❑2 INTERIM PERMIT ❑ AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED ! FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ _7 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS II. TANK CONTENTS IF(Al),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL N ❑3 CHEMICAL PRODUCT ❑N OIL ❑ 1 PRpDUCT ❑N GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.S.N: KIII- TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,A D A TYPE OF ❑ I DALE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ /SECONDARY CONTAINMENT ❑99 OTHER TANK ❑ i STEEUIRON ❑2 STAINLESSSTEEL [:] 3 FIBERGLASS ❑1 UHL OIED W/FIBERGLASS REWFUD PLASTIC B. MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑1 PHENOLICUNNG LINING ❑ 5 GLASS LINING ❑6 UNLINED 1 ) ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPADSU WITH 100%METHANOL' ❑YES ❑ NO ❑99 OTHER 0. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYLWMP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑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 2 PRESSURE A U 3 GRAVITY A U N OTHER S. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEI A U 3 POLYVINYL CHLORIDE(PVC) A U < FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S ll O METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S C ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED(MONTH 2 ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH -- SUBSTANCE REMAINING M GALLONS INERT MATERIAL+ ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINT FD A SIGNAL URF Dq El LOCAL AGENCY USE ONLY COUNTY N JURISDICTION # AGENCY N FACILITY ID N TANK 10 N ml� a� Lo I ULl CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE 6*1 Mil 7A PERMIT NUMBER PERMITAPPROVAL DATE PER IT ENPI ATION DATE GHECKI PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT/ BY: FORM B(3 7-BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED • DATA PROCESSING COPY 0