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I AINK F E+ PtkMIT APPLICATION INFOR(rTION COMPLETE A SE ATE FORM WITH THE FOLLOWING INFORMA&FOR EACH TANK. •Li MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT ONE ITEM 5 CHANGE OF INFORMATION �PERMANENTLY CLOSED TANK 2 INTERIM PERMIT A AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,''.-�n I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY / rhe FARM TANK YES NO A. OWNERS TANK IDN t p B. MANUFACTURED BY: C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: , � If. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A/),IS NOT MARKED,COMPLETE ITEM O. A A. - I MOTOR VEHICLE FUEL 0 2 PETROLEUMN B. C. ❑ I UNLEADED 0 2 LEADED D CHEMICAL PRODUCT 0 /PIE DIESEL 5,HAZARDOUS N I PRODUCT ❑L GASAHOL El 5 JET FUEL 0 6 AVIATION GAS ❑W EMPTY 95 UNKNOWN 2 WASTE El 1 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.6 D C.A S.N. A. TYPE OF ❑ I DOUBLE WALLED Lj 3 SINGLE WADED WITH EXTERIOR LINER SYSTEM E3% M 2 SINGLE WALLED �4 SECONDARY CONTAINMENT E399 OTHER B.TANK ❑ I STEEL/IRON 2 SINNTE55 STEEL 3 FIBERGLASS 04 STEEL CUD W/FIBERGLASS REINFORCED MATERIAL ❑5 CONCRETE 6 POLYVINYLCHLORIDE /ALUMINUM B 10016METHANOLCOMPAIIBIFFRP PLASTIC El 9 BRONZE 10 GALVANIZED SOW ED%UNKNOWN 99 OTHER C. INTERIOR 0 RUBBERLIKE) 2ALKYD LINING O3 EPDXY LINING 1 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED I I %UNKNOWN 0 IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL° ❑ YES F1 NO E]99 OTHER D.CORROSION O 1 POLYETHUNEWRAP 0 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 11 1 FIBERGLASS REINFORCED PU$TIC PROTECTION 0 5 CATRODICPROIECTION 091 NONE ED%UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE ECONSTRUCTION A u I sucnoN w u 2 PRESSURE w U 3 GRAVITY A U 99 OTHER A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U l STEEL/IRON A U 99 OTHER A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U A FIBERGLASS PIPE A U 5 ALUMINUM A U 6 CONCRETE A U ) STEEL CLAD W/FHP A U 81009`METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEL 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 A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S T PRESSURE IESTING P S 91 NONE P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESLIMATED DATE UST USED IMOIYRI 2 ESTIMATEDO REMAINING OF SUBSIgNCE RFMgININC IN T WASTANKERILI WITH GALLONS INERT MATERIALS YES 0 NO� THIS FORM HAS —_BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED K sK_ IOHII DAV FE I•. j TI LOCAL AGENCY USE ONLY n COUNTY N JURISDICTION N AGENCY _ J AGILITY IDN TANK ID N Iq RRENT LOCAL AGENCY FACILITY ID N ✓ / �PPROVED BY NAME PHONE N W ITN AREA CODE PERMIT NUMB PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT FaIM a 13.1•eel THIS FORM MUST BE ACCOMPANIED BY A FACIU`IY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED -------- -- DATA PROCESSING COPY