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AIV MC LEIaw `K-PERMIT APPLICATION INFORMAION COMPUTE A SEF`' TE FORM WITH THE FOLLOWING INFORMATI� OR EACH TANK. rd- MARIE ONLY ❑ ? NEW PERMIT ❑ 3 RENEWAL PERMIT Ld' CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEO PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV£0 FACILITY/SITE NAME WHERE TANK IS INSTALLED FARM TANK-VES❑ NO I. TANK OESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ;,c) A. OWNERS TANK IO N v, B. MANUFACTURED BY: C. YEAR INSTALLED T 0. TANK CAPAGTY IN GALLONS: I A II. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A-1).IS NOT MARKED,COMPLETE ITEM D. 113 A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑ 3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑{OIL ❑ 1 PRODUCT ❑ i GASAHOL ❑ S FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ ❑80 EMPTY 95 UNKNOWN 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) U. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED S C"A.S.It i 7 C.A.S.N: xIII. WANK CONSTRUCTION MARK ONE ITEM ONLY!N BOJ(A,B,C,8 0 A. TYPE OF ❑ ! LTOUBLE WALLED ❑3 SINGLE WALLED MnTN DI TERIOR LINER ❑95 UNKNOWN SYSTEM R 2 SINGLE WALLED ❑ 1 SECONDARY GDWANMENT ❑99 OTHER �STEEL I CONCRETE ETE ❑ 2 STAENLESSSTEEL ❑3 FIBERGLASS ❑{STEEL CLAD WIFIBERGU<SSREN{FORCFO?LASTN; MATERIAL ❑ S CONCRETE ❑S POLYVINYL CFLORIOF ❑ I ALUMINUM ❑B 100%METHANOL COMPARBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR I RUBBER LINED 2 ALKYD LINING -. 3 EPDXY LINING jPKENOLIClUNtNG- LINING ❑ 5 GLJSSLENING ❑6 UNLINED 1 f 95 UNKNOWN IS LINING MATERIAL COMPATIBLE MTN 100%MOHAMX-, YES NO ❑ 99 OTHER D.CORROSION ❑ I PCLYETrLENE WRAP ❑ 2 TAR OR ASPFIALI _ ❑ 3.VINYL WRAP ❑ {FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ S CAEHODICPROTECTKJN ❑91 NONE ff%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(3L? 3 CNAYITY A U 99 OTHER B.CONSTRUCTION A U ;1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH ^4f"UNKNOWN A U 99 OTHER A<Ui STEELORON A U :' STAINLESS SIEEL A U 3 POLYVINYL CHLORIDE IPVCI A U 4 F18ERGLASS PIPE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WJFTIP A U B 100%METHANOL COMPATIEILE FHP A U '9 GALVANIZE1)STLEL A U 95 UNKNOWN A U 99 OTHER i V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY-OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRC,ED. P S I VISUAL CHECK P .S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P.n¢ 7 PRESSURE TESTING P S 91 NONE �S 95 UNKNOWN - P S 99 OTHER - VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ��ESDMATE�OOATE STUSEDTMOJYRJ � �? E$[IMgFEDOUANii1YOF 3 WAS IANK FILLED WITH Sk1B$i qN[;F.RFMAINlNC IN INEHE MATERIAL'1 DYES ❑ NO � _ GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENAL 7Y Of PERJURY.AND TO THE BEST OF MY KNOWLEDGE."1S TRUE AND GORREC7 �li APPLICANT'S NAiyIF IPHINI F.t7 S St1:Nn t LIHII O E I - . LOCAL AGENCY USE ONLY COUNTY v JURISDICTION IT AGENCY r FACILITY IO N TANK 10 N L= LLD ri C URRENT LOCAL AGENCY FACILITY-to. APPROVED BY NAME I PHONE r WITH AREA CODE AMET NUMBERPERMIT APPROVAL DATE PERMIT ERPTAAT{ON DATE�{ECK r PERMIT AMOUNT SURCHARGE WMT. FEE CODE RECEIPT t OY T 'FORM B I3-7•aal THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM `A',UNLESS A CURRENT FORM W-:HAS BEEN FILED DATA PROCESSING COPY I ,�w.u..n _La•r�•"•�... . -,TaG19cr':i:'f:i:iuH..�r �. r .- - „ , "