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apry f( I ANIK PERMIT APPLICATION INFORMATION COMPLETE A SEI ITE FORM WITH THE FOLLOWING.INFORMAI jFOREACHTANK. '".. MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMA ION ❑ I PERMANENTLY CLOSED TANK ONE ITEM 2 INTEMMPERMIT ❑A AMENOEOPERMIT ❑6 TEMPORARY TANKCLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS 075iINSTALLED: �� /�/_i� FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ' I' to A OWNERS TANK IDI 0. MANUFACTURED BY: v. 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 D. A A ❑ I MOTOR VEHICLE FLEL ❑2 PETROLEUM 8. C. 1 UNLEADED ❑ ❑2 LEADED 7 DIESEL ❑ 7 CHEMICAL PRODUCT ❑ 1 OIL ❑ 1 PRODUCT ❑1 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ry ❑5 HAZARDOUS ❑ 00 EMPTY 95 UNKNOWN ❑2 WASTE ❑ I METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.A (,/. K, C.A.S.K L Xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,0,C,6 O A.TYPE OF ❑ I DOUBLE WALLED ❑7 SINGLE WALLED WITH EXTERIOR LINERQ9955 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ /SECONDARYCONTUNMENT ❑97 OTHER ❑ t STEEL/MN ❑2 STAINLESS STEEL ❑7 ROERGUSS ❑ /STEEL CLAD WIFISERfGASS2E9 FORCED PLASTIC B. MATERIAL ❑TANK S CONCRETE ❑6 POLYVINYL OIORDE ❑/I ALUMINUM ❑0 IBD%METHANOL COMPAIIBLERP C:]9 BRONZE ❑ 10 GALVANIZED STEAL U%UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALxYOUNING ._- ❑ 7 EPDXY LINING ❑A PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED I I d9;SNOWH ❑ ISUNING MATERIAL COMPATI&E WITH 100%METHANOL, ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 FOLYETHLDEWRAP ❑ 2 TAR OR ASPHALT a7 VINYL WRAP ❑ A RBERGLASSREINFORCED PLASTIC PROTECTION D 5 CATHODICPROTECTION ❑91 NONE Q 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 7 GRAVITY U 99 OTHER I B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 7 LINED TRENCH X-U 95 UNKNOWN- A U 99 OTHER A U ISTEEL/IRON A U 2STAINLESSMER A U 7 POLYVINYL CHLORIDE IPVCI A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM AY_y.rpNGREA U I STEEL CLAO W/FNP A U B 1W%METHANOL AOMPAIIBLE FRP A U 9 GALVANIZED STLEL 'A 9$95u_NKNp�wN\-1 A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. i P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 7 VADOSE WELLS P S A ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S I PRESSURE TESTING I c w- P S 95 UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED(MO/YR) ? TIM ESA IEDOUAN I I TY OF W T ASIANKEILLEDWITH _ I_ SUBS I ANCE HE MAINING IN GALLONS INERT MATERIAL' DYES ONO] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE ANO CORRECT APPLICANT'S NAME(IMIINI ED 5$II1Nn 1 VIII I J J n ' LOCAL AGENCY USE ONLY COUNTY A JURISDICTION Y AGENCY A FACILITY ID A TANK IO I Dz �_. q O O o 3 CURRENT LOCAL AGENCY FACILITY 10 A APPROVED BYNAME PHONE I WITH AREA CODE PERMIT NUMBER PERMIT A"ROVAL.DATE.. PERMIT EXPIRATION DATE CHECK A PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIIT E BY: FORM S(J-7-M) THIS FORM MUST BE ACCOMPANIED BY A FACILETYISITE APPLICATION, FORM 'A',UNLESS A'CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY aSM1,..rL..:.iP ....7':;.:u.afiilYtWYT+RYP.L..Lvu ...:x:u.•. cl._:.:.0 - ._:.. yam.._. .. _,...a:... :�_...._...,._._.A�..__....__. .. .. ._.....f.