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. _ . -..._ .... ..._. ............. I.vna^%,n i^rm. NZI 0 MARK ONLY ❑ 1 N PERMIT —13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION T PERMANENTLY CLOSED TANK ONE ITEM L 22 INTERIM PERMIT ❑ 1 AMENOEOPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO J _> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY / 10 A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. j V A ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C ❑ I UNLEADED ❑2 LEADED ❑ 3 DIESEL N ❑ 3 CHEMICAL PRODUCT 04011 ❑ 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY LA 95 UNKNOWN ❑2 WASTE ❑ l METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C A.S a C A.S.N Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,8 D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED 1 SECONDARY CONTAINMENT 99 OTHER TANK F1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑/STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIOf ❑ l ALUMINUM 6 1001 METHANOL COMPATIBLE FFP ❑ 9 BRONZE ❑ 10 GALVANIZED$TEE! ❑ 95 UNKNOWN ❑99 OTHER _ C. INTERIOR F1I RUBBER LINED --- ❑ 2 Al KYD LINING ❑ 3 FPDXY LINING — El PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ' l ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IW%MEIHANOI ❑ YES NO 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHAI I ❑ 3 VINYL WRAP ❑t FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A if ABOVEGROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 8. 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 OAON A U ? STAIN)ESS STFF A U 3 POLYVINYL CHLORIDE(PVCI A U 4 FIBERGLASS PIPE C. MATERIAL A U ', ALUMINUM A U 6 CONCRE II A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL!:OMPATIBLE FRP A U 9 CALVANIZ FU STE.EI 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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCI!IAT ION P S 7 VADOSE WEU S P S < ELECTRONIC MONITOR P S 5 GROUND WATFR MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATEODATE LAST USED!MO/YHI -- ---- ----- -- -- - -- - _ ESTIMAIF.D OUANTIIY OF I t WAS TANK E4LEDW IT h1 iSUIWOANCE REMAINING IN I INERT MATERIAL-' ❑YES ❑ NU� GALLONS THIS FORM HAS BEEN COMPLETED UNDER P[NAL lY OF PER./URY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT-NAMI I1-11INTI Tl.f SIGNA ILIR! OqF i LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N m / I A [7-1 CURRENT LOCAL AGENCY FACILITY 10• APPROVE7'1;4' ME,(�'J PHONE N WITH AREA CODE --_F / PERMIT NUMBER I PERMIT APPROVAL DATE kRMIT EX04PI N DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 1 BY: FORM B(3-7•BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILEO I DATA PROCESSING COPY _1