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TANK TAN' uERMIT APPLICATION INFORM -ION I COMPLETE A SEP._,.TE FORM WITH THE FOLLOWING INFORMATISSweOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM Fl 2 INTERIM PERMIT 1:1 1 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK 18 INSTALLED: FARM TANK-YES❑ NO ❑ _7 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID N \ Q n\L AA-, L' B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1 cTLXD A 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. N A II,MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C.-OLUNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ A OIL t&I PRODUCT ❑1 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 S.N C.A.S.N: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,6 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 LNGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOW SYSTEM -6Z12 SINGLE WALLED ❑1 SECONOARYCONTNN.ENT ❑99 OTHER I LINK STEEIN ❑2 STAIWESSSTEEL ❑ 3 FIBERGLASS ❑/STEEL CLAD WIRBRIGLAS$REINFORCED MASTIC i B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHAORIOF 7 ALUMINUM ❑6 HBO%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING /PHENDUCLIMNG LINING ❑5 GLASS LINING ,J ,DINED I 'Q %MMNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLEM WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑9 FIBERGLASS REINFORCED MASTIC 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 LA I SU,,TION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALLED A DpUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U %OTHER A U I STEELMRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U e FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U B 1089E METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A V 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 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S A ELECTRONIC MONITOR P 5 5 GROUND WATERMONITORING WELLS P 5 6 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN 99 OTHER t�S[Y'- Y�-1 clef_ VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATE DAT LAST USED IMO/YRI 2 ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH Y/ SUBSTANCE REMAINING IN GALLONS INERT MATERIAL'+ E] YES ❑ NO a THIS ORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 6 SIGN A i URF I D/H E� 1 J LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK 10 N m CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPNIATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORMS 13.7.88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM W,UNLESS A CURRENT FORMA' NAS BEEN FILED DATA PROCESSING COPY