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Ary■�'rt n I AERMIT APPLICATION INFORMI#ON , a ° COMPLETE A SEP E FORM WITH THE FOLLOWING INFORMATI OR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 1 PER NENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT El AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED JS Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: "� , r FARM TANK-YES❑ NO 6 _7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID N f B. MANUFACTURED C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1� II. TANK C LATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE IT O. A. Eg"I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. G ❑ I UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS N ❑ 5 HAZARDOUS BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C A.S.N C.A S.N. x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑ 1 DOUB WALLED rl 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM O NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PI TIC E B (�MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE T ALUMINUM B 1009E METHANOL COMPATIBLE FRP ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C.INTERIOR 1 RUBBER LINED 2 ALK INING F-1 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10091 METHANOL" YES 0 NO 99 OTHER D.CORROSION TASPHALT 3 VINYL WRAP El FIBERGLASS REINFORCED PLASTIC ❑ I POLYETHLENE WRAP U�-irf PROTECTION 5 CATHODIC PROTECTION 95 UNKNOWN El 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSU14F A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A .0 I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A Ul STEELMRON A U 2 STAINLESS SIEF-I A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U / STEEL CLAD W/FRP A U B 100%METHANOL COMPA1113LF FRP A U 9 GALVANIZED STEEL 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. T P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS mP S 6 PRECISION TESTING P S 7 PRESSURE TESTING91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED(MO/YR) ? ESTIMATED Ol1AN1DY OI 3 WAS TANK FILLED WI1H SUB`;l ANC[HE-MAINING IN INERT MATERIAL' ❑ YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OI PERJURY,AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT APPLICANTS NAMF(PRINIf D&SI,NAIUI-p I OrY E 1 / LOCAL AGENCY USE ONLY COUNTY N JURISDICTION 0 AGENCY N FACILITY IDN • TANK ID N LJ I Lo lo I / F. 1•c� 16161 CURRENT LOCL AGENCY FACILITY 10� / APPROVED Y_NAME � J �� PHONE 11 WITH AREA CODE c IPERIMAIT NUMBER MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE K 9 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT P BY: �y FORM B(3.7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM W,UNLESS A CURRENT FORMA' HAS BEEN FILED +'J DATA PROCESSING COPY ntif�i!'wy1�'Sc�iS�:i;;r:tiT� o::i�"ifiilSt,YI7RA�'.aE@L."I:Il`t':'�:i::i4.�:tK::,u:•.:r. - -