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ANK IANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK �' . • MARK ONLY ❑ I NEW PERMIT ❑ G RENEWAL PERMIT ONE ITEM ❑5 CHANGE OF INFORMATION I� /pFyMANENTLY CLOSED TANK ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE LT^�B/TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: a0 FARM TANK-YES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IFUIEKNOWN--BO SPECIFY ryp A. OWNERS TANK ID N 10 —� B. MANUFACTURED BY: G YEAR INSTALLED D. TANK CAPAGTY--I-, II. ANK CO NTS IF(A.1),IS MARKED.COMPLETE ITEM C.IF(A 1),IS NOT MARKED,COMPLETE ITEM D. �14nll- r�A I MOTOR VEHICLE FUEL ❑2 PETROLEUM N B' C. ❑ 1 UNLEADED ❑2 LEADED 9 DIESEL ❑J HAZARDOUS CHEMICAL PRODUCT ❑ 1 OIL I PRODUCT ❑A GA511NOL ❑5 JET FUEL FV ❑5 HAZARDOUS SO EMPTY ❑ ❑6 AVIATION GAS ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL ENTER NAME F HAZARDOUS SUBSTANCE STORED A C.A.S.N C.A.S.M. VIII. TANK CONSTRUCTION MAR ONE ITEM ONLY IN BOK A,B,C,AD A. TYPE OF ❑ I DOUBLE WALLED ❑7 WALLED MTN EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED1 SE CONTAINMENT E] ❑99 OTHER B. TANK I STEELIRON El2 STA STEEL ❑ J FIBERGLASS ❑1 STEEL CUD W/FIBERGLASS REN RWM PLASTIC MATERIAL ❑5 CANCRETE ❑6 POLW CNLCPoD ❑ 7 ALUMINUM ❑S ILEAL METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ ID GALVANIZ STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RIBBER LINED E12 ALKYD LINING ❑7 EPDXY LINING 1 PHENOLIC LHING LINING ❑5 GLASS LINING ❑61NUNED 1 1 ❑IS UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE MIN IBB%METHANOL, ❑YES ❑NO ❑99 OTHER 0.CORROSION ❑ i POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑y VINYL WRAP ❑ FNIERCAA55 REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 HONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I STICTION A U 2 PRESSURE A U ]GRAVITY _ A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED _ A U 2 DOUBLE WALLED A U ]LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 SIAINLESSSTEET U l POLYVINYL CHLORIDE IPVCI A U M FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE U STEEL CLAD W/FHP A U BIW1y METHANOL COMPALOLE FRP 9 A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR ECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. i P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S J VADOSE WEL S 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 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PL CE I ESTIMATED DATE LAST USEOIMO/YHlESTIMATED OUANIIIV Of WA$TANK FILLED WI TH _ T —SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑YES [:]ND� _ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND T THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT-S NAME(PRIN1 ED R SIGNA I tMI I DA,F!•. LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT L AGENCY F CILITY IDN APPROVED BY NAME ' O—1�6—96) PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE --- CHECK N PERMIT AMOUNT SURCNMGE AMT. FEE CODE RECEIPT N BY: FORM807-08) THIS FORM MUST BE ACCOMPANIED BY A FACILITYZSITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED I DATA PROCESSING COPY '•B�Sii,,'9rSTi8!G%:.i7 w•L1Ii'i'Avtit.F:xcmr-. .:;..Mu;.. ... .„a.,.. _..:M_,a.�.........�_. . _ _