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I AIV K I AT&PERMIT APPLICATION INFORf&TION <br /> COMPLETE A SE, ATE FORM WITH THE FOLLOWING INFORMA FOR EACH TANK , <br /> 1. <br /> MARK ONLY ❑ I NEW PERMIT E]3 RENEWAL PERMIT <br /> ONE ITEM 5 CHANGE OF INFORMATION F1 7 PERMANENTLY CLOSED TANK <br /> 2 INTERIM PERMIT O/AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE fTZ <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: L�6 TANK REMOVED <br /> • �2 ""� FARMTANK-YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— <br /> SO SPECIFY <br /> A. OWNERS TANK IO 0 10 <br /> 1. B. MANUFACTURED BY: <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(At),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE IT D A <br /> A. I MOTOR VEHICLE FUEL 2 PETROLEUM N <br /> B' G ❑ 1 UNLEADED 2 LEADED 'J <br /> 3 CHEMICAL PRODUCT �/OIL �3 DIESEL IV <br /> I PRODUCT 0/GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS BD EMPTY 0 95 UNKNOWN 2 WASTE 11 1 METHANOL 99 OTHER)DESCRIBE IN ITEM D.BELOWI <br /> D. IF NOT MOTOH VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&CAS N <br /> C.A.S.p'. <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C,8 D <br /> A TYPE OF ❑ I DOUBLE WALLED 3BNGLE WAUEDMTN FJ(iER10R LINER 95 UNKNOWN <br /> SYSTEM 2 SNGIE WALLED /SECANOAIT/CONIMNMENT <br /> 99 OTHER <br /> B.TANK ❑ I STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS E]1 STEEL DAO W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE E]6 POLYVINYL CH�OR10F 7 ALUMINUM E]B 100%MERMOL COMPATIBLE FW <br /> 9 BRONZE 10 GALVANIZED STEP %UNKNOWN %OTHER <br /> C. INTERIOR ❑ I RUBBER LINED El 2 ALKYD LINING Ej 3 EPDXY LINING 1 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED I f <br /> %UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' YES �NO �99 OTHER <br /> D.CORROSION E] I POLYETHLERE WRAP 2 TAR OR AShMLT _- ❑3 VINYL WRAP <br /> PROTECTION 1 FIBERGLASS REINFORCED PLASTIC <br /> 5 CA DO <br /> PROTECTION 91 NONE 95 UNKNOWN <br /> %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 <br /> U 3 GRAWTY A U 99 OTHER <br /> B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN <br /> A U I STEEL/IRON A U 99 OTHER <br /> A U 2 STAINLESS$TEFI A U 3 POLYVINYL CHLORIDE(PVCI A U • FIBERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE <br /> A U 1 STEEL CLAD W/FRP A U B I(M1y METHANOL COMPALDLE FHP <br /> A U 9 GALVANIZED SiLEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE JESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1 ESTIMATED DATE LAST USED(MO/YH1 <br /> 2 ESTIMATED QUANTITY Of <br /> SUBSIANGE REMAINING IN T WAS TANK FILLED WITH <br /> - -- GALLONS INERT MATERIAL' E]YES E] IN <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'$NAME(PRINIF'D A SIGNn RIH(I <br /> DA, <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION M - <br /> I1�I' AGENCY F FACILITY I <br /> TANK ID M <br /> CU T LOCAL AGENCY FACILITY 10 0 <br /> APPROVED BYNAME PHONE Y WITH AREA CODE <br /> NUMBER - -"- <br /> ERMIT APPROVAL DATE PERMIT EKPIRATION GATE <br /> CHECK a PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPTS in <br /> FOR1A 013-7-881 THIS FORM MUST BE ACCOMPANIED OVA FACIUTT/SITE APPLICATION, FORM W.UNLESS A CURRENT FORMA' NAS BEEN FILED <br /> -------- -.. DATA PROCESSING COPY <br />