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TANK TA�PERMIT APPLICATION INFOR, TION s; 4 COMPLETE A S ATE FORM WITH THE FOLLOWING INFORMA- _I FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM E] 2 INTERIM PERMIT El AMENDED PERMIT El TEMPORARY TANK CLOSURE ®8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: *7'700 MbteIV, Cf 94 kN FARM TANK-YES❑ NO ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I O A. OWNERS TANK IDM C�) i B. MANUFACTURED BY: C. YEAR INSTALLED O D TANK CAPACITY IN GALLONS: 11L 000 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.11),IS NOT MARKED,COMPLETE ITEM D. N A. ® 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM 8. C. ® 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL N ❑ 3 CHEMICAL PRODUCT 04011 © 1 PRODUCT ❑ 1 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.a CAS M x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ® 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER .TANK 1 STEEL/IRON ❑2 STAINLESS STEEL El FIBERGLASS ❑/STEEL CLAD W/FIBERGLASS REINFORCED RKTIC A B MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑/PHENOLICUNING LINING ❑ 5 GLASS LINING ❑6 UNLINED ' ®95 UNKN0WN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOLS ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑/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 99 OTHER LAKN B. CONSTRUCTION A I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A LY 99 OTHER A U 1 STEEL/IRON A U 2. STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 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(MO/YR) 2 ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NU� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT"$NAME(PRINTED 6 SIGNATURE) D/1,E I LOCAL AGENCY USE ONLY CO�UNTYY M� JURISDICTION k AGENCY x Lolo FACILITYY 10 M TANK ID M I I I I L-1 `=iJ-� L l lo FoTt-1 CURRENT LOCAL AGENCY FACILITY 10 M APPROVED BY NAME PHONE II WITH AREA CODE PERAlt NUMBItR PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• ey. — FORM-B(3-7-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM ' UNLESS A CURRENT FORMA' HAS BEEN FILED ,�T \ DATA PROCESSING COPY \\ V ` J