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I A11K 1ACALPERMiT APPLICATION INFORTION COMPLETE A S ATE FORM WITH THE FOLLOWING INFORMA FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ONE ITEM 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK . ❑2 INTERIM PERMIT ❑ AMENDED PERMIT ®6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: h /I m 1114D I FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY '? A. OWNERS TANK ID p ®, to B. MANUFACTURED BY: C. YEAR INSTALLED at O. TANK CAPACITY IN GALLONS: Cro II. TANK CONTENTS IF(A.1).IS =�3-rthb MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ('V A. I MOTOR VEHICLE FUEL ®2 PETROLEUM B. C. ❑ i UNLEADED ®2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OILi PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS IU ❑5 HAZARDOUS ® 80 EMPTY �95 UNKNOWN ❑2 WASTE � 1 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHIGLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.p: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.d o A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UFL(NOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER B I STEELIIRON 2 STAINLESS STEEL f—]3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS RENFORCE0 PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE I ALUMINUM f—]8 IOD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ IO GALVANIZED STEEI ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ t RUBBERLINED ❑2ALKYD LINING F3 EPDXY LINING4 LLINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ! N-9-5MNKNO'WN IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL" YES ❑NO n 99 OTHER 0.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 0 91 NONE Lej 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH AOP 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS Sl EFI A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/F P A U B I00%METHANOL COMPAIIBI_f FNP A U 9 GALVANIZED SILEL A U 95 UNKNOWN A 99 OTHER LIr 4P / /Q 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 & S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S 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 V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t ESTIMATED DATE LAST USED(MO/YR) WAS TANK FILLED WITH -T - 7 ESTIMATED QUANTITY OF --- 3 SUBSIANCE REMAINING IN INERT MATERIAL, YES NO -- __ GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENAL TY 01 PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED d SIGNAL tIIIE 1 D7t E�•. LOCAL AGENCY USE ONLY ENUMBER RISDICTION p AGENCY a FACILITY 10 0 TANK ID N ILITY IO a APPROVED BY NAME PHONE R WITH AREA CODE ----�-__._._._ fZ (? VrERMIT EXPIRATION DATE AMOUNT SURCHARGE AMT. FEE CODE RECEIPT p FORM a 13.7•ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BYc BEEN FILED DATA PROCESSING COPY �fL`I!MQ1iTeLc�i� frSltuN•i•' tlitca>a;i -az:r._r:�...,:Iw....<:c�.,,:wssu•.ex. :-c........w...<•....:........«..�.....»... .. _