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TANKTANAPERMIT APPLICATION INFORNSION . . COMP E A SE4 TE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. � MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ T PERMANEN Y CLOSED TAN ONE ITEM F] Z INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED �I FACILITY/SITE NAME WHERE TANK IS INSTALLED: / (( FARM TANK-YES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIF- I O A. OWNERS TANK ID K B. MAS 4LJFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. i V A ❑ 1 MOTOR VEHICLE FUEL F--] 2 PETROLEUM B C 1 UNLEADED 2 LEADED ❑ 3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑ < OIL ❑ 1 PRODUCT ❑ E GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ® W EMPTY ❑95 UNKNOWN ❑ 2 WASTE I METHANOI. ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED d C A-&II C,A.S.If All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,8,C,A D A- `TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM D 2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER F-1i STEELHRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑/STEEL CUD WIFIBERGLASS REINFORCED PLASTIC8. TANK MATERIAL [—] 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ I ALUMINUM ❑9 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTFEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F11 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOUCLINING LINING ❑ 5 GLASS LINING F-16 UNLINED I ❑%UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOLS ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑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 A U 99 OTHER B. CONSTRUCTION A V I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEELMRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U a FIB€RGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A U B IDD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL. A U 95 UNKNOWN A U 99 OI HER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S d ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE IESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED(MOfYR) 2 ESTIMATED QUANTITY OF _ 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MAT€RIALI Q YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT$NAVE(PRINTEDASiGNATUM D/� Ea•. I LOCAL AGENCY USE ONLY COUNTY x JURISDICTION M AGENCY# FACILITY ID R TANK ID# CURRENT LOCAL AGEN FACILITY 1011 APPROVED BY NAME PHONE II WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXPIRATION DA I CHECK t PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT P BY: I oRM B 13 7-ea) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM"A` HAS BEEN FILED qllI - DATA PROCESSING COPY r