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TAq&PERMIT APPLICATION INFORh&ION TANK COMPLETE A SEPIWATE FORM WITH THE FOLLOWIr INFORMATMR FOR EACH TANK. P+'i• RT 3 RENEWAL PERMIT S CHANGE OF INFORMATION I PERMANENTLY CLOSED TANK MARK ONLY F-1I NEW PEMI ❑ ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSUHE E]8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLEO:/;,&?O �✓ Wqq FARM TANK-YE5 NO .r I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK 10 N U pt, B. MANUFACTURED BY. C. YEAR INSTALLED 13,73 D TANK CAPACITY IN GALLONS: II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. fV A. 0 1 MOTOR VEHICLE FUEL F-12 PETROLEUM B. C I UNLEADED ❑2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE El I METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW( D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C_A.S h C.A-S.N. KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ II DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ' { �2 NGLEWALLED 4 SECONOARYCONTAINMENT ❑99 OTHER ��ta4ww I STEELI IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W!€IBERGUSS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE 1 L-1 6 POLYVINYL CHLORpDE ❑ 1 ALUMINUM ❑8 10094 METHANOL COMPATIBLE FRP MATERIAL � ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN a 99 OTHER ❑ C. INTERIORI RUBBER LINED F-12 VOLINING ❑ 3 EPDXYLINING E] 4 PHENOLICLINING LINING ❑ 5 GLA{,S LINING JW'UN 1 ❑%UNKNOWN IS LINING MATERIAL COMPATIBLE WIT 00%METHANOL' ❑ YES ❑ NO ❑99 OTHER ll D. CORROSION ❑ I POLYETHLENE WRAP LLJ2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN 99 OTHER_ IV. PIPING. INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A&I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH ACU 5 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE{PVC) A U 4 FIRERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD WlFRP A U 8 100%METHANOL COMPAT18LE FRP A U 9 GALVAWZED STEEL A. UI 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY-OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. PS I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED WO/YR} — -T 2 ESTIMATED QUANTITY OI —3WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL" ❑YES 0 NO THIS FORM HAS BEEN COMPLETED LINGER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLVCANT"S NAME(PRINTED A SIGNATURE I 07E'! I r j i LOCAL AGENCY USE ONLY COUNTY u JURISDICTION N AGENCY N FACILITY ID N TANK ID A [iff] L I I I I I Lob po N CqRjtENT LOCAL AGENCY FACILITY ID N APPROVED By NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK s PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT f BY: kF0jHMB(3-?-&8) LIC THIS FORM MUST BE ACCOMPANIED BY A FACILITY/S1TE APPATION, FORM W,UNLESS A CURRENT FORMA' HASBEENFILED OATH PROCESSING COPY r