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r I AnK I AMMERMIT APPLICATION INFORMMION COMPLETE A SE TE FORM WITH THE FOLLOWIN INFO RMATIWOR EACH TANK. � > o MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE Of INFORMATION ONE ITEM ❑ 1 PERMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ° CJ FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY '? co A. OWNERS TANK IDN B. MANUFACTURED BY: VK C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: U. TANK CONTENTS IF(A,1),13 MARKED,COMPLETE ITEM C.IF(A 1),IS NOT MARKED,COMPLETE ITEM D. 1� I N A• 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ t UNLEADED El2 LEADED 3 DIESEL `C E]3 CHEMICAL PRODUCT ❑ OIL t EfPRODUCT ❑4 GASAHOL ❑5 JET FUEL E]6 AVIATION GAS N ❑5 HAZARDOUS ❑BD EMPTY [:]95 UNKNOWN ®2 WASTE ❑ 1 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N C.A.S.I. Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C.&D A.TYPE OF EJLPM8LEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER El 95 UNKNOWNSYSTEM 2 SINGLE WALLED ❑e SECONDARY CONTAINMENT ❑99 OTHER B.YANK I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CLAD W/FIBERGLASS rtwFORRCEO PLASTIC r MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 1 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZEDSTEEI ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑e PUENOLICLINING LINING ❑5 GLASS LININ, ❑6 UNLINED ! 95 tNq(NOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI WRAP ❑e FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNOERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A I SUCTION A U 2 PRESSURE A U 3 GRAVITY ___ A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALLED — A U 2 DOUBLE WALLED A U 3 LINED TRENCH A,51>95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FHP JA U 6100%M TMANOL COMPATIBLE FHP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 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 6),S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 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. ESTIMATED DATE LAST USED(MO/YR) - _ ESTIMATED QUANTITY Of =INERT WAS TANK FILLED WITH SUBSI ANCE REMAINING IN MATERIALS GA ❑YES EnNU] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINT EDS SIGNA I LFII'I D�E�•. LOCAL AGENCY USE ONLY COUNTY a JURISDICTION 9 AGENCY• FACILITY 10 M TANK IO I LojiE511 CU RENT LOCAL AGEN Y FACILITY 10• APPROV D BY AME - PHONE N WITH AREA CODE e2� r� c� . [PERMIT NUMBER PERMIT APPROVAL OATS PERMIT EXPIRATION DATE CHECK A PERMIT AMOUNT SURCHARGE AMT. FEE CODE —'-- RECEIPT! BY: FORM 813.7•ea) THIS FORM MUST BE ACCOMPANIED 8Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM°A° HAS BEEN FILED DATA PROCESSING COPY r.3:t•yaa3,:+.sAse�:l:r.•r-.. 1 ,R1,..,