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MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT L „ GHANGE OF INFORMATION ❑ )PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑ 4 AMENDEOPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED -2- FACILITY/SITE ZFACILITY/SITE NAME WHERE TANK IS INSTALLED: /Lc/ I' Y/ - C eV r//� FARM TANK•YES❑ NO Rr 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1 p FAOWNERS TANK ID N B. MANUFACTURED BY-EAR INSTALLEO D. TANK CAPACITY IN GALLONS. 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. A N A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM 13 C ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ I PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BD EMPTY L] 95 UNKNOWN ❑2 WASTE ❑ ) 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 Alll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.IL D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER____ __ ❑ . TANK B I STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGUSSREOFORCEDPLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 1 ALUMINUM ❑B 100%METHANOL COMPATIBLE FEW ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBER LINED - - ❑2 AtKYOIJNING-- - El3 EPDXY LINING ❑ 1 PHENOLIC LINING -_ LINING ❑ 5 GLAS�,LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH LOOK METHANOL' ❑ YES ❑ NO ❑ 99 OTHER---___ D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 1-11 FIBERGLASS REINFORCED PLASTIC 5 CATHODIC PROTECTION ❑ 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALLED_ A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL,IRON A U 1 STAwL ESS STEN A U 3 POLYVINYL CHLORIDF(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U ', ALUMINUM A U 6 CONCRE TI A U 7 STEEL CLAD w/FHP A U B 100%ME THANOL COMPA TOLE FNP A U 9 GALVANIZE D STI.EI A U 95 UNKNOWN A U 99 OT/LER 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 VADOSE WELL S P S 4 ELECTRONIC.MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S / PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE --I ESTIMATE-()DATE LAST 11SED IMO/VH1 .' ESTIAIAIED WAS TANK fII LEU 3UR[IAN(;E REMAINING IN INERT MATERIAL' F--]YES F-] NO-- - -- -- ___ _ _ _ GALLONS L _ THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT C NAI+1 IPPlNII P till;NAll 11141 Dq f LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY 10 N TANK ID N cl F7-1 > It/ I W] 1, 1 1 1 1 •. CURRENT LOCAL AGENCY FACILITY 10• - APPROVED SY NA E _-PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPgOVAL DATE PERMIT EXPIRATI� OATS CHECK• PERMIT AMOUNT SURCHARGE ANT. FEE CODE gECEIPT 1 SY; FORM B(7-)•BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM W,UNLESS A CURRENT FORMA• NAS BEEN FILED DATA PROCESSING COPY .........�.