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MARK ONLY ❑ I NEW PERMIT ❑ ] RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONEl 2 „ ONE ITEM ❑ ❑ 7 PER ANENTLY CLOSED TANK FACILITY/SITE NAME WHEREN7ANK SINSTALLEO;mly IAMENDEO PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED /J� 111 G'9 Ry( FARM TANK-YES NO _> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY to A. OWNERS TANK IDA __ _ B. MANUFACTURED BY: C. YEAR INSTALLED D TANK CAPACITY IN GALLONS II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O- A A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 0 C. ❑ I UNLEADED ❑2 LEADED D DIESEL N ❑ D CHEMICAL PRODUCT ❑ A OB N ❑ I PRODUCT Cj 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 00 EMPTY [A 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER)DESCRIBE IN ITEM 0.BELOW) O. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C A.S.a C.A.S.a .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.8 D A. TYPE OF ❑ I DOUBLE WALLED ❑ 9 SINGLE WALUDNITHEIRERIDR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED [:14 SECONOARYCONTMNMENT ❑W OTHER ❑ B. TANK I STEEL/IRON ❑ 2 STAINLESSSIEEt -- ❑ 7 FRIEWAASS El STEEL DIAD YEIFIBEFIGASS RENFORCEO RASTIC ❑ MATERIAL 5 c&acE 6 POLYVINTL C40RO ❑ 7 ALUMIMIM ❑Y 10D%METHANOL COMPATIBLE FEW ❑ 9 BRONZE ❑ IO GALVANIZED SIM ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑ 2 At KID LININ; ❑ B FPOAYLINING ❑1 RENOLK:LIMNG LINING ❑ 5 GUSSLRNING ❑6 OrtIMO ' ❑95 UNKNOVM ❑ ISLINING MATERIAL COMPATIBLE MIH ILO%WTHANO' YES ❑NO Ej 99 OTHER_ D. CORROSION ❑ I POLYETHLENEWRAP ❑ 7 TAR OR ASPHMI ❑ B,, WRAP ❑1 FIBERGUSSREINFORCEDRASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONI ❑ 9511NKN0WN 9901HEfl____ ___-__-_____ IV, PIPING INFORMATION CII4CLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I STICTION A U 2 PRESSURE A U 9 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED _ A U 9 LINED TRENCH A U 95 UNKNOWN A U 99 DINER A U ISTEEUIRON A U ' SIAINIESSVEEI A U 3P0ILYVINYLCHLORIOFIPvC.I A U N FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRF II A U % STEEL CLAD W/FRP A U 81BB1y METHANOL COMMA IIpIE FHP A U 9 GAL VANIlkll lll,fl A G YS UNFH(1WM1 A U '14 0111QI1 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 5 2 INVENTORY RFCONCILIAIION P S I VAUUSf.[I I!, P S N ELECIRONIC MONITOR P 5 5 GROUNR WATER MONITORING WELLS P S 6 PRECISION TESTING P S 1 PRESSURE IESIING P S 'JI NONE P S 95 UNKNOWN P S %OTHER VI. INFORMATION ON,TANK PERMANENTLY CLOSED IN PLACE I FSTIMAIFDDATELASI U%n MOIYRI - , ISIIM-TH)UIIA NIIIYGF I l WASIANK LILLEDWIIII i MIIt`.InMIE HI'MAININfi IN INflil MATERIAL ❑ YES ❑ NO GALLONS L PHIS FORM HAS BEEN COMPLETED UNDE--R PENAL IY.u ?I(I(,IUHY,AND TO THE OES F OF MY KNOWLEDGE.IS TRUE AND CORRF(.1 APPLICPNI C NAME IPgINII(I(gl,iNn 1up OK5 E'•. I LOCAL AGENCY USE ONLY COUNTY R JURISDICTION a AGENCY, FACILITY ID A TANK ID a CURRENT LOCAL AGENCY FACILIT9'ID• --' -- APPpOVEO BY N E PHONE I WITH AREA CODE PERMIT NUMBER ' PERMIT APPROVAL GATE PERMIT EXPIRATION GATE_-- �_— ------- CHECK• PERMIT AMOUNT SURCHARGE AMT, FFE CODE RECEIPT• ---_-- ----- er: FOFTIM80.7-BB) THIS FORM MUST BEACCOMPANIED BY AFACILITY/SITE APPLICATION, FORM 'A' UNLESS A CURRENT FORM'A' HASBEENFILED I DATA PROCESSING COPY • • J