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v a /'1 � L. V 1 \,/tea..■ � v r a■ � an rrM � �n n�ovr✓n�.�.� vv�� nVL ovMnv /+- •..••-.^+;• F M'B': UNDER _ROUND STORAGE TANK PRC1- 7AM ❑ 2 WASTE YANK TANK ERMIT APPLICATION INFORM.- , iON ® 3 FIBERGLASS ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. \F' •o'er ❑ 5 CONCRETE MARK ONLY ® 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ❑ 9 BRONZE ONE ITEM [:]2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 1 RUBBER LINED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES ❑ NO Elf I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN —SO SPECIFY ❑ 5 GLASS LINING. A. OWNERS TANK ID # 4 0B. MANUFACTURED BY: Xerxes C. YEAR INSTALLED 19 90 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. '�X,' 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL [a 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, &b A. TYPE OF U-1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION ❑ 1 STEEL/IRON 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER FIBERGLASS PIPE A U 91 NONE 1 RUBBER LINED F—]2 ALKYD LINING ❑ 3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING. ❑ 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A EgIS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 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 0 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 1 VISUAL CHECK P(g5 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 �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 N/A GALLONS INERT MATERIAL? N /A❑ YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICAN NAME(PRI E &SI ATURE) Frances W. Hedric DATE Agent for ARCO Barghausen Consulting Engineers, Inc. (916) 348 305 Z 10 I•'t' LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # m CURRENT LOCAL AGENCY FACILITY ID # FACILITY ID # TANK ID # APPROVED BY NAME PHONE # WITH AREA CODE IPERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE --� _ rNFrK a ovgYlT n_MOtlNT Si Toru! R^E.4!'.. rEE CODE I F ECZ1PT X FORM B (6-29.9a) THIS FORM MUST BE ACCOMPk,:D BY A FACILITY/SITE APPLICATION, FORM W, UNLES.� A CURRENT FORMA' HAS BEEN FILED ,!A -F3, PROCESSING CC