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F ,RM'B': UNDER'^ -ROUND STORAGE TANK PROf'QAM TANK _-RMIT APPLICATION INFORM01OFI 'cw�' �v �� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. \``l/ MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES ❑ NO !. TANK DESCRIPTION COMPLETE ALL ITEMS- IF UNKNOWN —SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: Xerxes C. YEAR INSTALLED 1990 D. TANK CAPACITY IN GALLONS: 10 , 000 II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A.1' 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 12 1 PRODUCT 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 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.A.S. # C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑X 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN A U 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 715 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A F-11 RUBBER LINED F-]2 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING. ❑ 6 UNLINED U 6 CONCRETE ❑ 95 UNKNOWN U 7 STEEL CLAD W/FRP ❑X SIS LINING MATERIAL COMPATIBLE WITH 100%METHANOI? YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC 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 U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A O 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A 04 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM. A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 I VISUAL CHECK P 65 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN (7)S 99 OTHER Red Jacket PLD VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH N/A SUBSTANCE REMAINING IN I N /A GALLONS INERT MATERIAL? ❑ YES N /A ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICA 'S NAME (PRI/NTEDBSIGNATURE) Frances W. Hedric DATE — c��'�ti/ L(% I� Agent for ARC0 C CQ LOCAL AGENCY USE ONLY Barghausen Consulting Engineers, Inc. (916) 348. 305 COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE S z� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Ll zq CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT # I BY: FORM 8 (6-29-88) THIS FORM MUST BE ACCOMPt _0 BY A FACILITY/SITE APPLICATION, FORM `A', UNLI!;,, A CURRENT FORMA' HAS BEEN FILED D:,TA PI r_ COPY