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r TANK TANK "'ERMIT APPLICATION INFORMA—ON COMPLETE A SEPAk.,E FORM WITH THE FOLLOWING INFORMATIOE,, IJR EACH TANK, MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 1 PERMANENT ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMO FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN Q B. MANUFACTURED IN- C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IFUII ISMARNcn___-_-- CLO R" - A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ I UMFADED ❑ 2 LEADED ❑ 3 DIESEL Iv ❑ 3 CHEMICAL PRODUCT ❑ A OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS N ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) ❑ 3 FIBERGLASS 0. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF MATERIAL HAZARDOUS SUBSTANCE STORED 8 CAS. N CA S. N. 6 POLYVINYL CHLORIDE X11 TA\IV ^ ❑ S 10A ME7Hg0 COMPATIBLE FRP ^•••• •^•�•� VVI�JITIVl. 11VI•E MARKONEITEMONLYINBOXA-B-C.AD A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WAILED WITH DOERIOR LINER ❑ 95 IMmm SYSTEM ❑ 2 SINGLE WALLED ❑ A SECONDARY CONTAINMENT ❑ 99 OTHER B. ❑ I STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 1 STEEL CUD W/FIBERGLASS REINFORCED MASTIC MATERIAL ❑ 5 CONCRETE❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 10A ME7Hg0 COMPATIBLE FRP 3 LINED TRENCH A U ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBERLINED ❑ 2 ALKYD LINING ❑ 3 EPOKYLINING ❑ 1 PHENOUCLM IG LINING ❑ 5 GLASS LINING ❑ 6 UNLINED I ❑ 9S UNKNOWN 5 ALUMINUM ❑ IS LMNG MATERIAL COMPATIBLE WITH 100%METHAN01 I ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHEWWRAP❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ A FIBERGLASS REWORDED MASTIC PROTECTION ❑ $ CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION rIRrl F A IC AR V 1.1-11 11 ___..._-__.._-_ _ V. A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CIAD W/FRP A U B 10R METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER LtAK Ut I tGT10N SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST RF CIRrI En S I VISUAL CHECK P S 2 1NVENTORLYRECONCILIATIOM P S 3 VADOSE WELLS P S A ELECTF40NIC 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 N OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMO/YRI 2 ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIALI YES ❑ NO - - •- " I 1 yr rtndunT, ANU IV Int Dt5 F UE MY KNOWLEDGE, IS TRUE AND CO APPLICANT .9 NAME (PRINTED A SIGNAWEIF I DAI EI n' 7RECT w L.AL. AVCIYI-T UJt VINLT COUNTY N JURISDICTION K AGENCY N FACILITY ID N TANK ID N 1-T CURRENT LOCAL AGENCY Ft$I ITY 10 E APPROVED BY NAME PHONE I WITH AREA CODE PERMIT NUMBER ,N/(f/(�j� PERMIT APPROVAL DATE ►ERW EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPN - ---- --• ^�-•---��-.�LI�,. o•,. �,.�I�II FIJI It ArnwADuN, rvnm A, UNLESS A CURRENT FORMA• HAS BEEN FILED DATA PROCESSING COPY