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TANK TANMF-RMIT APPLICATION INFORRA&ION ; COMPLETE A SEd. TE FORM WITH THE FOLLOWING INFORMATIWVOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 0 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED '02- 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: © e +op-j FARM TANK-YES❑,WO -7 L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK IDM ` B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: (�6vo II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C- ® 1 UNLEADED ❑2 LEADED 19 3 DIESEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ /OIL I PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS El 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C A.S.M CAS-0 ,LIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,6 D A TYPE OF ❑ 9 YJBLE WALLED Ll OX 3 SINGLE WALLED WITH. TERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGIE WALLED ❑ /SECONDARY CONTAINMENT ❑99 OTHER i STEEIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑+STEEL UAD WIRBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ I ALUMINUM ❑8 100%METHANOL COMPATIBLE HIP ;? MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING F-] 3 EPDXY LINING ❑1 PHENOLIC LINING C. W RIOR �l 5 GLASS LINING UNLINED + E]95 UNKNOWN LININIS LINING MATERIAL COMPATIBLE``111"'"ITH 00%METHANOL' ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP L.0 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 VIKRGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHOOICPROTFCTlON ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 1 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 A 05 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PNC) A U 4 FIBERGLASS RIPE C. MATERIAL A U S ALUMINUM A ,+.�fY6 CONCRETE A U 7 STEEL CLAD WIFRP A U 8 IRO%METHANOL COMPATIULE FRP A U 9 GALVANIZED STEEL A (U p5 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. P S IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 1 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 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 IMOFYHI- - - - 2 ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH SLIBSIANCE REMAINING IN INERT MATERIALS ❑GALLONS YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT I APPLICANT'S NAME(PRINTED 8 SIGNATURE I DAIE I f LOCAL AGENCY USE ONLY COUNTY K JURISDICTION M AGENCY k FACILITY 10 M TANK IO II I I 1 -1 1 1 1 -1 �F/TilI ' b I nO Z- CL(RENT LOCAL AGENCY FACILITY 10 M APPROVED BY NAME T PH NE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER 6T EXPIRATION DATE CH CK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT I BY: 1 FORMS(3-7-sal THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY