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HnIK 'A"K PtFIMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK- �•�T!y/'y� MARK ONLY ❑ 1 NEW PERMIT •" o RENEWAL ONE ITEM ❑O AMENDED PERMIT ❑5 CHANGE OF INFORMATION � 2 INTERIM PERMIT ��AMENDED PERMIT RY 7 PERMANENTLY CLOSED TANK FACILITY/SITE NAME WHERE TANK IS INSTALLED; S 1:1 6 TEMPORATANK CLOSURE 6 TANK REMOVED O I. TANK DESCRIPTION COMPLETE ALL ITEMS'IF UNKNOWN_SO SPECIFY FARM TANK-YES N A. OWNERS TANK ID N 1 CJ B. MANUF C. YEAR INSTALLED ACTURED By, 1 NK rAPArjw .I.. 11. TANK C NTENTS IF(A.1(,IS PARKED,COMPLETE ITEM C.IF(A-1),ISNoMARKED.COMPLETE E ITEM D. d A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM A B G N ❑D CHEMICAL PRODUCT ❑ ❑ 1 UNLEADED ❑2 LEADED DIESEL � /al ❑ 5 HAZARDOUS ❑BO EMPTY 95 UNKNOWN PRODUCT ❑/GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS N ❑ ❑2 WASTE (OESC 1:199 OTHER RIBE IN ITEM D,BELOW) D. If NOT MOTOR VEHICLE F EL,ENTER NAME OF ❑ T METHANOL HAZARDOUS SUBSTANCE S RED 6 C.A.S.K .III. TANK CONSTRUC ON MARK ONE ITEM ONLY IN BOX A B,C,&D CAS.[ A TYPE OF ❑ I OOUBLEWALLED ❑7 SINGLE WAILED WITH EXTERIOR LINER SYSTEM ❑2 SNGLE WALLED1 SECONDNNCONTANMENT ❑95 UNKNOWN ❑ ❑99 OTHER S. TANK 1 MATERIAL ❑ 5 STEELARO 2 STAINLESS STEEL ❑7 FIBERGLASS ❑1 STEEL CLAD WIRBEAGUSSREYEDACED PLASTIC CONCRETE 6 POLYVINYL MOROF 1:1 /ALUMINUM ❑6 1000 METHANOL COMPATIBLE TRP El 9 BIONZE 0 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERLINED ❑2 DLINING F-]J EPDXY LINING ❑R PHENOLICUMNG LINING ❑ 5 GLASS LINING ❑6 UNL 0 1 f ❑25 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH LOOM RMNOL, ❑YES ❑NO ❑99 OTHER 0. CORROSION ❑ 1 POLYETHUNEWRAP ❑2 TAROK 1 .. ❑7 VINYL WRAP ❑1 FIBERGLASS REWORDED PIASFC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN 099 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROU D. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SU TION A U 2 PRESSUR A U J GRAVITY A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WA ED A U J LINED iflENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS Si -1 A U J POLYVINYL CHLORIDE IPVCI A U FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETI A U ) STEEL CUD W/FNP A U 5 SYDk METHANOL COMPAIIDLE FNP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S F SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 J VADOSE W LS P S A ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELL$ P S 6 PRECISION TESTING P S /PRESSURE TESTING P 5 91 NONE P S 95 UNKNOWN P S "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PL CE 1 ESTIMATED DATE UST USED IMO/YR1 - - 2 ESTIMA1fD Dl1ANIIIY Of J WA$IANK FILLED WITH SUBSTANCE REMAINING IN ALLONS [:]INERT MATERIALI ❑YES GNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO E BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT'$NAMf IMIINIFO A SIGNAL URi I D E!-. LOCAL AGENCY USE ONLY COUNTY E JURISDICTION M AGENCY[ FACILITY ID F TANK ID[ �_ �_ �_ Cha � l �'• �� DO CURRENT La AGENCY CILITY 10 A APPpO ED BY NAME --- O _ ! _ /JD P/10NE 1 WITH AREA CODE PERMIT NU4lER - PERMIT APPROVAL DATE l/D- O - -- - - PERMIT EXPIRATION OATS CHECK E PERMIT AMOUNT SURCHARGE ANT. FEE CODERECEIPT - -DIY_ FgIM B 1I T BB) THIS FORM MUST BE ACCOMPANIED SYA FACLLITY/AR APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED ---- -___ _ DATA PROCESSING COPY