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OFFOR M� ��r� UNDER CATER RESOURCES CONTt 7� UN FACIL1fY/S��GRO UMD STORAGE TANK �r pR�?gTIpM and/or PROGRqW COZ:PLETE THIS FORM FOR EACN P CI TM�sfr APPLICATION � LIARCC ❑ grlory �°T OFd�r 1 NEW PERMIT ONE ITEMS El ❑3 RENEWAL PERMIT 2 INTERIM PERMIT ❑5 CHANGE OF fNFORk4 TION cameo 1' FACILITY/SITE INFORMATION A AD a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ❑ 7 PERMANENTLY CLOSED SITE ❑ FACILITY/SITE NAPE. ESS—" (MUST BE COE9PLETED) _ r ADDRESS / z CARE OF ADDRESS �� / INFORMATION EST CROSS STREET it C{ I NEAR CITY NAME 4116 / f I ❑ eNmr to 'TL El❑ ACB 'GN 0 NCI FEDEPRSTATE 21PCODE DUAL ❑ COUY-AGENCY -AGENCY TYPE OF BUSINESS. CA SITE PHONE#,WITH AREA CODE ❑2 DISTR'BUTOR n 4 PROCESSOR ✓Box if INDIAN EPA ID k ❑f GAS STATM ❑ 3 FARM 5 OTHS RESERVATION or ( ' EVERGENCY CONTACT PERSON(PRIMARY) TRUST LANDS ❑ r( Yt 1 #Of TANK'S AT IS SITE DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON(SECONDARY) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,F;RS J PHONE#WITH AREA CODE PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) IJ PHONE#WITH AREA CODE II. PROPERTY OWNER INFORr dATION&ADDRESS— (MUST BE COMPLETED) NAME I /' ' CARE OF ADDRESS INFORMATION r f MAILING 0,,STREET ADDRESS-, ..( � (/ i'J y L r ✓ to indicate ElPARTNERSHIP ❑ STATE-AGENCY t CORPORATION ❑ LOCAL-AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY �- s ` STATE ZIP POE PHONE#,WITH AREA CODE M. TANK OL"JNER INFORMATION &ADDRESS— MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADORE SS .1r ✓ to indicate 11PARTNERSHIP + I. ORPORATION 11LOCAL-AGENCY 13 STATE-AGENCY 13 FEDERAL-AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY /r P STA ` ZIP ODE PHONE#,WITH AREA CODE LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH AICOIIIZ ADD:%=SHOULD BE USED FOR DOTH LEGAL NOTIFICATION AND BILLING: 1. II. ❑ 111 ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE )CAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE RRENT LOCA"GENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE R91T NU M13ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ATION CODE CEN US TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE IFIL D YES ❑ NO ❑ I A i CK# PERMIT AMOUNTI SURCHARGE AMOUNT FEE CODE RECEIPT k BY: A FORM>wUST BE ACCOCPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS 1S A CHANGE OF SITE INFORLIATION ONLY. J \.. FILE COPY UNDERGFIOU"D STOKt'►""- I�FpR�{ATwry „. FIQ,RI9A `B': TANK PERMIT APPLICATIOW ION FOR EACH T `` � SEPARATE FORM WITH THE FOLLOWING INFORMATAN �_ _� COMPLETE A SEP5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ❑ t NEW PERMIT El3 RENEWAL PERMIT ❑8 TANK REMOVED r MARK ONLY ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ONE ITEM ❑2 INTERIM PERMIT r FARM TANK-YES❑ NO ❑� FACILITY/SITE NAME WHERE TANK IS INSTALLED: CIFY I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO S B MANUFACTURED BY: t A. OWNERS TANK ID if t � r D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED L( • 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPALDEE E ITEM D.LEADED 3 DIESEL B. C. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM E:] 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑h4 J k 1 PRODUCT ❑5 HAZARDOUS 'CO EMPTY ❑95 UNKNOWN ❑2 WASTE ID METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF , j C.A.S.N: HAZARDOUS SUBSTANCE STORED&C.A.S.0 / !7 Jll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,8,D X TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMSL�+GLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER []�?-ITEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASSREiNFORCEDPLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATI3LEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C.INTERIOR F-11 RUBBER LINED F-12 ALKYD LINAG ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASSLINING I. UNLINED ❑95 UNKNOWN ❑ ISLNINGMATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER [D.CORROSION ❑ I 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 U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE 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 'UJ 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ' P 6 PRECISION TESTING P S 7 PRESSURE TESTING L+ S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID#IJ A I I L :E] Ll I o< W I / I 617R_-/1 1 . �� CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY N/)ME PHONE#WITH AREA CODE i PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3a-88) THIS FORM MUST BE ACCOUPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED — FILE COPY