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jl AW,*4T. ST , RN WATER RESOURCES CONTR 30ARD k got F lJND GROUND STORAGE TANK PROGRAM TA TANK PERMIT APPLICATION INFORMATION ® Y 2 1 O, *LETE A SEPARATE FORM WITH THE FOLLOWING J,INFORMATION FOR EACH TANK. 3 RENEWAL PERMIT [ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CI-qSED -ja4 OWRIW T/S10Kffiim PERMIT F-1 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 6 1 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: (,A)A-reALOO S ELL IC60b &7FARMTANK-YESE] NO [K I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A OWNERSTANKIDN MANUFACTURED BY: AP F-,C- C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: _T 000 --.j 11. TANK CONTENTS IF(A.11),IS MARKED,COMPLETE ITEM C.IF(A.11),IS NOT MARKED,COMPLETE ITEM D. A. rX 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL r-] 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS E] 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&C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF F-] 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 0 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER pa I STEEL/IRON ❑ 2 STAINLESS STEEL F-]3 FIBERGLASS F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-] 5 CONCRETE ❑6 POLYVINYL CHLORIDE r-1 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL [:] 9 BRONZE ❑ 10 GALVANIZED STEEL E] 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-] 1 RUBBER LINED ❑ 2 ALKYD LINING El 3 EPDXY LINING E]4 PHENOLIC LINING LINING F-1 5 GLASS LINING 6 UNLINED -] NO ❑ ❑ 95 UNKNOWN [_] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? [_❑YES 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP F-]4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 21 95 UNKNOWN F] 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U I SUCTION A 0 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A (U) 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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. IP,,,� CP l VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER-Pf VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH L SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] NO THIS FORM H S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APP ZCANT'SNA"ERINTED&SIGNA U DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCYd FACILITY 10# TANK ID# LL I I I? I -&To-] L 1 1 -141 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY ZNA ONE#WITH AREA CODE "tA, 4'-I—ooz 7— PERMIT NUMBER PERMIT APPROVAL DATII!6i PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. BY: gR.CHARG FEE CODE RE'-'PT FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BTAI;ACIL17Y/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY