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TANK TANK PERMIT APPLICATION INFORMATION ;, COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 'tl.• - MARK ONLY 1 NEW PERMIT � 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 21NTERIMPERMIT ❑ K AMENDEOPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED, 8 FARM TANK-YES[A NO 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN-80 SPECIFY I p A. OWNERS TANK ID N O B. MANUFACTURED BY. Le K LC. YEAR INSTALLED D TANK CAPACITY IN GALLONS J' IL TANK CONTENTS IF(A.T),18 MARKED,COMPLETE ITEM C.IF(A.1I,IS NOT MARKED,C ETE ITEM D. ` ? N A MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C I UNLEADED ❑2 LEADED ❑3 DIESEL CD 3 CHEMICAL PRODUCT ❑1 OIL �PROOUCT ❑1 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS N ❑ 5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN L❑J2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM 0.BELOW 0. IF NOT MOTOR VEHICLE FUEL ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C A.S.N CAS.N. MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B.C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONDARY CONTARAENT ❑99 OTHER El STEEUMgN ❑1 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CLAD WIF18ERGLASS RENFORCED"TIC a MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ i ALUMINUM ❑8 100%WTHANOL COMPATIBLE FRP ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 ODER C. INTERIOR ❑ I RUBBER LINED ❑2 MAYOLNNG ❑3 EPOAYLINING ❑1 PHENOLICUNING LINING ❑ 5 GLASS LINING ❑6 UNLINED I ❑IS UNKNOWN ❑ IS UNNG MATERIAL COMPATIBLE WITH IOD%METHMgLI ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHU E WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑N FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 ODER 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 %OTHER A S.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 IPVCI A U I FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 IDD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U %UNKNOWN A U 99 OTHER D 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 A 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 %OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED IMOYYRI 2 ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL° ❑YES ❑ NOO ] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED A SIGNATURE) OA,4'E I LOCAL AGENCY USE ONLY COUNTY* JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOC AGENC FACILITY 10 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER _— PEAMIT APPROVAL DATE RMIT EXPIRATION DATE _ CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BC FORMBR3-7-88I THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSACURRENT FORMA' NAS BEEN FILED DATA PROCESSING COPY