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TANK TANK&RMITAPPLICATION INFORMAMN `\ COMPLETE A SEPA FORM WfTH THE FOLLOWING INFORMATIO R EACH TANK, MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑T PERMANENTLY CLOSED TANK ONE ITEM E] 2 INTERIM PERMIT E]4 AMENDEDPERMIT 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �G � � _ �- FARM TANK-YES❑ NO ❑ .� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Ep A. OWNERS TANK IDM _ B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS- 11. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A N A ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM e. Fc [E-::] I UNLEADED ❑2 LEADED ❑3 DIESEL❑ 3 CHEMICAL PRODUCT ❑ /OIL ❑ I PRODUCT 1 GASAHOI ❑5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑2 WASTE T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED S.C.A.S.N C.A.S.k. MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,8 O A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINUSSSTER E] 3 FIBERGLASS ❑/MR DAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYL CKOMDE ❑ T ALUMINUM ❑B 100%ME71IANOl C0IAPATIBLF FRP MATERIAL ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑/PNENOLK;LIMNG LINING ❑ 5 GLASS UNING ❑6 UNLINED ( ❑95 LAKNLYWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10014 METHANOL? ❑ YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHIFNE WRAP ❑2 TARORASHIALT ❑3 VINYL WRAP ❑1 RBERGIASS REINFOFaD 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U N OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U %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 ( STEEL CAD W/FRP A U 8 1804.METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S N ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S % OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OFT_ 3 WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONB INERT MATERIAL' ❑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(PRINTED 8 SIGNAT DRF I Oq E I J P LOCAL AGENCY USE ONLY COUNTY K JURISDICTION M AGENCY N FACILITY ID 0 TANK 10 N CURRENT LOCAL AG)ENCY FACILITY ID N APPROVED BY NAME PHONE F WITH AREA CODE dK et PERMIT NUMBER PERWT APPROVAL OATS RMIT ATION DATle CNECKI PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT( BY: FORM B 137-BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM•A• HAS BEEN FILED DATA PROCESSING COPY j