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E HIVK I A.IvK PthMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ONE ITEM ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑2 INTERIM PERMIT A AMENDED PERMIT ❑ Z PERMANENTLY CLOSED TANK FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑6 TEMPOgARry TANK CLOSURE Q'B TANK REMOVED L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- FARM TANK-YES❑ NOV❑ SO SPECIFY o A. OWNERS TANK IDR to C. YEAR INSTALLED B. MANUFACTURED BY: 11. D. TANK CAPACITY IN GALLONS:TANK CO TENTS IF(Ll) IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A A MOTOR VEHICLE FUEL ❑2 PETROLEUMN ❑3 CHEMICAL PRODUCT E] I OIL B ❑ ' UNLEADED LQ4 LEADED ❑3 DIESEL El 5 HAZARDOUS PRODUCT ❑I GASAHOL ❑5 JET FUEL E]6 AVIATION GAS N E]60 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ / METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N .111. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOX A.13,C.8 D C.A.S.R. A TYPE OF ❑ I DOW W'7LL ❑3 SINGLE WALLED NTH EXTERIOR EWER ❑ 95 UNKNOWN! NTI SYSTEM 0 SINGLE WALLED ❑ I SECONDApYCONINNMENT ❑99 OTHER B. TANK [-] I STEELNRON ❑2 STAINLESS STEEL 3 FIBERGLASS MATERIAL ❑SCOIICRETE ❑)STEEL GAD W/FBEpGA$S REINFORCED PLASTIC ❑6 POLYVINlI GLORKIF i ALUMINUM ❑$100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑%UNKNOWN ❑99 OTHER ❑ 2 ALKYD LINING C.INTERIOR 1 RIBBER LINED ❑ 7 EPDXY WING ❑I p11ENpLIC IYNNCi UNING ❑5 GLASS LWYIG 6 UNUMEO I 1 ❑%UNKNOWN ❑IS UNNGMATERALCOMPATI&F TH I(O%METHANOL ❑YES ❑NO ❑99 OTHER 0. CORROSION ❑ I POLYETHENE WRAP ❑2 MORASPIML7 ❑J VINYL NMP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A 11 ABO GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 ESSURE A U 3 GRAVITY A U 99 OTHER I B.CONSTRUCTION A U I S NGLE WALLED A U 2 BLE WALLED A U J LINED TRENCH A U 95 -- UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STM LESSSTf E1 A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 GONG TE A U STEEL CLAD W/FRP A U BIW%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKN ) N A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY. R S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 5 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 DOSE WELLS P S I ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 5 91 NE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED N PLACE 1 ESTIMATED OA TE LAST USED IMO/YHI _ - __ 2 ESTIMATED WANTIi Of T WAS TAW FILLED WITH SUBSIANCf REMAINI IN INERT MATERIAL'GALLONS ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.A D TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME IPRINIfDA$I GIA 1111111 DAt 1,•. I P LOCAL AGENCY USE ONLY COUNTY A JURISDICTION 0 AGENCY$ FACILITY ID R TANK 10 M �_ _ CURRENT AGENCY FACILITY 101 APPROVED SY NAME HONE F WITH AREA CODE o � PERMIT NUMRER PERMIT APPROVAL MAY, PERMIT EEWRATNJN DATE CHECK• PERMIT AYOUNT SURCHARGE AMT. FEE CODE RECENRR BY: FORM80.7HM) THIS FORM MUST BE ACCOMPANIED BY AFACILRY/SRE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASSEENFILED DATA PROCESSING COPY 1- :dRvS5119R. ,5.'[f'KN6L:Iit�iAlMfl)l�Err:LTi::u.KalHca+....,:...M.•.,.:.�...��.. ..:.._..:....,....