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TANK IANK I&MIT APPLICATION INFORMATW ° y <br /> COMPLETE A SEPARA FORM WITH THE FOLLOWING INFORMATION EACH TANK. <br /> MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT ©5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLO <br /> SED TANK <br /> ONE ITEM 0 2 INTERIM PERMIT 0 A AMENOEOPERMIT F-1 6 TEMPORARY TANK CLOSURE El 8 TANK REMOVED Ia <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: a F CgJq o � C c FARM TANK-YES NI <br /> -7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Ip <br /> A. OWNERS TANK IDN B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D TANK CAPACITY IN GALLONS: <br /> - II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A <br /> N <br /> A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C 1 UNLEADED ❑2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 1 OIL I PRODUCT 1 GASAHOL 13 5 JET FUEL 06 AVIATION GAS N <br /> 0 5 HAZARDOUS 0 80 EMPTY ❑95 UNKNOWN [E::]] <br /> 2 WASTE ❑ 7 METHANOL C]99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 CAS.K C.A.S.N: <br /> .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,6 D <br /> A TYPE OF 0 DOUBLE WALLED 3 SINGLE WALLED 00TH EXTERIOR LINER 95UNKNOWN <br /> SYSTEM F-1 2 SINGLE WALLED 1 SECONDARY CONTAINMENT 93 OTHER <br /> I STEEUIRON 2 STAINLESS STEEL 0 3 FIBERGLASS 1 STEEL CUD W/FIBERGLASS RENRXaD PLASTIC <br /> B MATERIAL ❑ 5 CONCRETE E]6 POLYVINYLCHLORIDE ❑ 1 ALUMINUM 8100%METHANOL COMPATIBLE FRP <br /> - - 0 9 BRONZE E] IB GALVANIZEDSTEEL 0 95 UNKNOWN 99 OTHER <br /> C. INTERIOR ❑ 1 RUBBER LINED El 2 ALKYD LINING 3 EPDXY LINING A PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING El 6 UNLINED 1 Ej 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WIN 100%METHANOL7 YES NO [- <br /> -]99 OTHER <br /> D. CORROSION ❑ I POLYETHIFNE WRAP 2 TAR OR ASPHALT 3 VINYL IAP 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION E]91 NONE ED95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U "OTHER <br /> B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U ISTEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U < FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B IOD%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 I VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S A ELECTRONIC MONITOR _P S 5 GRCUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' YES Ej NO <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(PRINTED A SIGNATURF I DR EI. <br /> j it <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID M <br /> m [� � <br /> / y c <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE E WITH AREA CODE <br /> PERMIT NUMBER PERMITAPPROVALDATE PERMIT KPIRATIONDkfE <br /> CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT/ Byo <br /> FORMB(3-7.88) THIS FORM MUST BE ACCOMPANIED BY A FACIUTY/SITE APPLICATION, FORM 'A',UNLESSACURREM FORMA' HAS BEEN RILED <br /> DATA PROCESSING COPY <br />