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I ANK rAN ERMIT APPLICATION INFORM�ION 9�I1 COMPLETE A SE E FOAM WITH THE FOLLOWING INFORMATI FOR EACH TANK. •�'tl.�,. / ie MARK ONLY ❑ 1 NEWPERMIT ❑ 3 flENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM 02INTERIM PERMIT PERMANENTLY CLOSED TANK / AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED (7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 19 FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDX to U. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A A_ MOTOR VEHICLE FUEL ❑2 PETROLEUM I� 9. C. ❑ I UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑1 OIL PflODUCT ❑1 GASAHOL ❑5 JET FUELN ❑ 5 HAZARDOUS BO 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 OF HAZARDOUS SUBSTANCE STORED A C.A.S.X C.A.S.X. x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C.8 D A TYPE OF ❑ I DOUBLE WAILED ❑3 SINGLE WALLED MEN EXTERIOR LINER95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 1 SECONDARY CONTAINMENT ❑99 OTHER B. TANK 1 STEEUIRDN ❑ 2 STAINLESS STEEL 0 3 FIBERGLASS 0 1 STEEL CLAD WIFISEWAASS REINFORCED"TIC 5 CONCRETE 1 MATERIAL ❑6 POLYVINYL CN,ORIDF ❑ /ALUMINUM 118 IID%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEI ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYOUNING ❑ 3 EPDXY LINING ❑1 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLIMD 1 r ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL, ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETE%ENE WRAP ❑2 TAI OR ASPHALT ❑ 3 VINYL WRAP ❑1 FIBERGLASS REINFORCED PUSTC BE. ❑ 5 CATHODIC PROTECTION ❑91 NOM ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED_ A U 2 DOUBLE WALLED A U J LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FHP A U B IOOIb METHANOL COMPATIBLE FRP A U 9 GALVANIZED STLEI A U 95 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE LESTIMATED DATE LAST USEOIMO/VRIESTIMATED OUANTIIY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERTMATERIALS ❑ � _ GALLONS YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PBINI FD A SIGNATUNT) DAI E! I J a LOCAL AGENCY USE ONLY COUNTY X JURISDICTION X I AAGENCY7I A FACT TANK ID N f-TLOCALAGEAPPROVED BY NAME PHONE X WITH AREA CODE PERMIT APPROVAL DATE (ERMIT E[PIRATION DATE SURCHARGE AMY. FEE CO DE RECEIPT IT Y. fogMB13.7AB1 THIS FORM MUST BE ACCOMPANIED BYAFACIIJ ISQEAPPLICATION, FORM 'A',UNLESS ACURRENT FORMA' HASBEENFILED� DATA PROCESSING COPY e+�M1H.:.T+L?71'&F.T."i'IL ...'..tliiY.tL`.`J1Y�EFAIBCiSLv:uesiYmnc v:r...l,:w.u.a;.:.:�.umvn. .