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TANK TAN "ERMIT APPLICATION INFORN -ION 4:� \ �a3 p COMPLETE A SE►vATE FORM WITH THE FOLLOWING INFORMAThFIFOR EACH TANK. EFACILITY/SITE NLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION EM ❑ 2 INTERIM PERMIT ❑ /PERMANENTLY CLOSED TANK ❑ /AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- FARM TANK•YES❑ NO ❑ SO SPECIFY A. OWNERS TANK ID N10 N K I 8. MANUFACTURED BV: C. YEAR INSTALLED I 0� D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.I),IS MARKED,COMPLETE ITEM C.IF(AA),IS NOT MARKED,COMPLETE ITEM D.CR O A A MOTOR VEHICLE FUEL ❑2 PETROLEUM E, C TV �7� ❑3 CHEMICAL PRODUCT ❑1 OIL 'y� � ❑ 1 UNLEADED ED ❑3 DIESEL N PRODUCT 1 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑S HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) 0. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A S.X C.A.S.N. XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED NTH EXTERIOR LINER i,-VNKMOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER y B. TANK �+STEEUIRON ED STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUDW/FIBERGLASS REWfORCED FUSTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CIEORGE ❑ l ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RIIBBERUNED ❑2 AIKYDLINING ❑3 EPDXYLINING ❑1 RENOUCLIMNG LINING ❑ 5 GLASSLNIMi E94-LILINED 1 ❑95 WJ40WN ❑ IS LINING MATERIAL COMPATIBLE NTH 100%METHANOL, ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I PDLYETMEHEWRAP ,,,...dd❑�--�,,22 TAR OR ASPHALT LT ❑ 3 VWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION El CATHODIC PROTECTION may' NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE AU I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U MOTHER iB. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U Z STEEL CLAD W/FRP A U B IWHY METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AIG>5 UNKNOWN A U M 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 I VAOOSE WELLS P S < 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 W OTHER Lin_ L,Q(aML VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED OUANTITY'OF3 WAS TANK FILLED WITH r SUBSTANCE REMAINING IN INERT MATERIALALL '+ ❑YES ❑ NOGONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED A SIGNATURE! Dq E�•. LOCAL AGENCY USE ONLY COUNTY I JURISDICTION N I((�AAGENC'YI N�I FACILITY ID N TANK 10 N CURRENT LOCAL AGENCY FACILITY 10 F APPROVEO BY NAME PHONE X WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT X BY: FORM B O 2-N) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ACURRENT FORMA' NAS BEEN FILED ! DATA PROCESSING COPY