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I ANK IANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC MARK ONLY 131 NEW PERMITH TANK ' ONE ITEM ❑7 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑2 INTERIM PERMIT ❑/AMENDED PERMIT �A❑7 PERMANENTLY CLOSED TA FACILITY/SITE NAME WHERE TANK 18 INSTALLED: ❑6 TEMPOfWry TANK CLOSURE NK REMOVED G OF I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN SO/SPECIFY FARM TANK-YES 0 NO A. OWNERS TANK 10 R B. MANUFACTURED BY: C. YEAR INSTALLED 10 D. TANK CAPACITY IN GALLONS: IL TANK C ENTS IF(A1),18 MARKED,COMPLETE ITEM C.IF(At), NOT MARKED,COMPLETE ITEM O. A A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM N B. C ❑ I UNLEADED. ❑2 LEADED O DIESEL J CHEMICAL PRODUCT ❑ /OIL T'V ❑ I PRODUCT ❑/GASAMOL ❑5 JET FUEL E]6 AVIATION GAS 5 HAZARDOUS ❑BD EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ /METHANOL ❑99 OTHER(DESCRIBE M ITEM D.BELOW) D. IF NOT MO70R VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STO ED 6 C.A.S.E Kill. TANK CONSTRUCT N MARK ONE ITEM ONLY IN BOA A.B.C.8 D CAS.E. A TYPE OF ❑ I DDUREWNLED ❑J SNGUWALUDMTHEXIERKIRLINER 095 UNKNOWN SYSTEM 0 2 SINGLE WALLED ❑/SECONDARfOONTAINMENT ❑99 OTHER TANK I STEELIIDN 2 STAINLESS STEEL ❑9 FIBERGLASS B. 0 I STEEL CIAO WIFBERGLA55 REIEOICFO FUSTIC MATERIAL ❑5 CONCRETE 6 POLYVINYL CHLORIDE El i ALUMINUM ❑9 BRONZE10 GALVANIZED STEEL ED 95 UNKNOWN ❑w 100%METHANOL COMPATIBLE FOP C. INTERIOR ❑ I ROBBERIINED ❑2 KYO LINING ❑7 EPDXY LINING ❑1 PHENOLICLMNO LINING ❑ 5 GLASS LINING ❑6 RED f I ❑%UNKNOWN ❑ IS LINING MATERUL COMPATIBLE MTH IBOY HANOLI ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHUNEWRAP ❑2 TABOR I .�.. ❑ J VINYL WRAP ❑1 RBERDIASS IEIIR9RCED FIASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GRO D. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSU _ A U ]GRAVITY A U "OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE LLED A U ]LINED TRENCH A U 95 UNKNOWN ._ A U "OTHER A U 1 STEEL/IALUMINUM A U 2 SIAINLESSS fl A U 3 POLYVINYL CHLORIDE IPVCI A U A FIBERGLASS PIPE C. MATERIAL A U S ALUMINUM A U 6 CONCRETf A U / STEEL CLAD W/FNP A U R 1001b METHANOL COMPATIBLE FRP A U 9 GALVANIZED$ILEI A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S OR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S ]VADOSE ELLS P S A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN ACE 1 ESTIMATED GATE UST USED IMO/YNR 2 ESTIMATEO OUANIRY0F ] WAS TANK EILLED WDH GALLONS �O SUBSTANCE REMAINING IN INERT MATERIAL' ❑YES ❑ NO I J THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME TPNINIFO A 5111NA1Lllll I DY5 E!•. LOCAL AGENCY USE ONLY •��C..ODUNTYY N JURISDICTION F AGENCY E FACILITY ID I ZED=� � � TANK ID E _ _ O CURRENT L AGENCY F CILITY ID E _ APPROVED BY NAME — -- PHONE E WITH AREA CODE PERWTNUMBER 0,4 PERMIT APPROVAL DATE PERMIT EEPIIUATION DATE -- CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECENT• RY: `ORM B 1]7-PBI THIS FORM MUST BE ACCOMPANIED BY A FACILITTISITE APPLICATION, FORM'A',UNLESS A CUSSENT FORMA' NAS BEEN FBFD DATA PROCESSING COPY