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TANK TANI- OERMIT APPLICATION INFORM' -ION I, I�x)v 3 COMPLETE A SEF',..ITE FORM WITH THE FOLLOWING INFORMATI,,.orOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5❑ CHANGE OF INFORMATION Z INTERIM PERMIT E]ONE ITEM ❑4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED TANK 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN—SO SPECIFY A. OWNERS TANK 10 N T �L / 1 O R. MANUFACTURED BY: U C. YEAR INSTALLED 14 1 D. TANK CAPACITY IN GALLONS. 11. TANK CONTENTS IF(At),IS MARKED,COMPLETE ITEM C.IF(&I),IS NOT MARKED,COMPLETE ITEM D. S A. t I MOTOR VEHICLE FUEL ❑2 PETROLEUM TkfR2 N ❑33 CHEMICAL PRODUCT ❑A OIL C- ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL N RODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 EMPTY ❑ 95 UNKNOWNASTE ❑ 7 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 CAS.N. ,III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM S1� 2 SINGLE WALLED ❑A SECONDAA/CONTAINKIII ❑99 OTHER S VL I I STEEL/ROM ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑15TEEL CLAD W/fBEA$S fENIfORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORCE ❑ 1 ALUMINUM ❑B 10011,11ETHANOLOOMPATNXE ERP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I TEARER LINED ❑2 ALXYO LINING ❑ 3 EPDXY LINING ❑1 PNENOLICLBNNG LINING ❑5 GASS LINING ZL6 UNWED M ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%MFTN IT ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHENEWRAP ❑2 TAR KM ASPHALT ❑ 3 VINYL WRAP ❑A FIBERGLASS RENEOR(FD PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION R91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNO, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A GRAVITY A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER A U t STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETEA U I STEEL CLAD W/FRP A U B I(D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A e3 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S %UNKNOWN P S MOTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH 1,0 _a IV—IV-13_ 7 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑ YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANTS NAME IPRINTFO 6 SIGNATURE I D^E ii LOCAL AGENCY USE ONLY COUNTY$ JURISDICTION N AGENCY N FACILITY ID N TANK ID N m CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE -- CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: 1 fgiMB431-88I THIS FORM MUST BE ACCOMPANIED BYAFACIIITY/SITE APPLICATION, FORM 'A',UNLESS ACURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY v► � •ms:Aaa,.aaPanavwmm>c:v,..,.....:a....,a-,: -.>....,: ..�. _. -.._ _ .,.._...: .._...�..._.,...__._......._.