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TANK TANK -ERMITAPPLICATION INFORM/ 'ON <br /> COMPLETE A SEPA4fE FORM WITH THE FOLLOWING INFORMATI~. OR EACH TANK. <br /> MARK ONLY I NEW PERMIT Ej 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM E] 2INTERIM PERMIT 01 AMENDEDPERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED ;/ <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-VES LJ NO <br /> �7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Ip <br /> A. OWNERS TANK IDA IT MANUFACTURED BY <br /> ' C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS' <br /> A <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. I MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL N <br /> 7 CHEMICAL PRODUCT 1 OIL 1 PRODUCT E1 A GASAHOL Ej 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY F]95 UNKNOWN 0 2 WASTE E] 7 METHANOL 99 OTHER(OESCRISE IN ITEM D.BELOW) <br /> D, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.A C.A.S.A'. <br /> .111, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C.A D <br /> A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WIN EXTERIOR LINER 0 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALLED 1 SECONDARY CONTAINMENT O 99 ODER <br /> I STEEL/pN711 2STAINLESS STEEL 3HBERGIA$$ 151EEL CLAD W/FBERGIASSREAfORCED PLASTIC <br /> B. TANK 5 CONCRETE <br /> MATERIAL 6 POLYVINYLOLOIAOE 7 ALUMINUM 0 6 100%METIMNOL COMPATIBLE Ftp <br /> 9 BRONZE E] 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ I RUBBERUNED El 2 ALKYD LINING 3 EFOXYLINING [j 1 PHENOJCLIMNG <br /> LINING ❑ 5 GLASS UNING ❑6 LIMINED 1 ❑95 UM(NOWN <br /> IS LINING MATERIAL COMPATIBLE MTB 100%METHANDE YES [:]NO El 99 OTHER <br /> 0. CORROSION ❑ i POLYETHLENEWRAP 1:12 TARORASPHALT E]3VINYL WRAP /FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHOLIC PROTECTION O 91 NONE El 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUNO, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> i A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U "OTHER <br /> 1 B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U %UNKNOWN A U "OTHER <br /> A U ISTEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE)PVC) A U A FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WERE A U 8 LOOS,METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S t VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S W OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATEOOUANTITY OF 3 WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL' O YES NOGALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTEDA SKNATURFI <br /> 1 / <br /> _ b <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY A FACILITY IDA TANK ID A <br /> L I I / 'IV- <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME <br /> PRONE F WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE IMERNT EXPIRATION OkW <br /> I <br /> CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 1 er: <br /> FORM B(3-am) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN RLEO <br /> DATA PROCESSING COPY <br /> 1 <br />