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WATER RESOURCES CONTRO OARD <br /> -. -. <br /> FARM B6 UN .. ROUND STORAGE TANK RO A W..rhf J <br /> _ <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK, COMPLETE A SEPARATE FORM WITH THE FOLLOWINGINFORMATION FOR EAC"TANK. a <br /> MARK ONLY ❑1 NEW PERMIT 3 RENEWAL PERMIT 10 <br /> ONE ITEM ® CHANGE OF INFORMATION 7 MANENTLY CLOSED NK <br /> 2 INTERIM PERMIT 04 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z,O <br /> 101 <br /> FARM TANK-YES❑ NO W <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> FA. OWNERS TANK ID# —El <br /> B. MANUFACTURED BY: <br /> R INSTALLED G`]-7 D. TANK CAPACITY IN GALLONS: <br /> II. TAN ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C PLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. [Ti UNLEADED ®2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT. 4 OIL <br /> �IPRODUCT ®4 GASAHOL ❑5 JET FUEL M 6 AVIATION GAS <br /> 5 HAZARDOUS ®80 EMPTY `❑95 UNKNOWN 2 WASTE ❑7 METHANOL [:]99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> C.A.S.#f <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,e,C,&D <br /> A.TYPE OF ❑I DOUBLE WALLS 3 SINGLE WALLED WITH EXTERIOR LINER . �95 UNKNOWN <br /> SYSTEM C)2 SINGLEWALLED Il/SE(V"RYCONTAINMENTE199 OTHER <br /> B.TANK <br /> D 1 STEEUIRDN 2 STAINLESS STEEL ®3 FIBERGLASS f-�4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ®5 CONCRETE ❑6 POLYVINYL CHLORIDE 7 ALUMINUM F-1 8 100%METHANOL COMPATIBLE FRP <br /> CJ 9 BAIZE 10 GALVANIZED STEEL ®95 UNKNOWN ❑99 OTHER <br /> C.INTERIOR ❑ 1 RUBBER LINED F-1 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING <br /> LINING ❑5 GLASS LINING 0 6 UNLINED ®95 UNKNOWN <br /> El S LINING MATERIA.COMPATIBLE WITH 100%METHANOL? YES ®NO ❑99 OTHER <br /> D.CORROSION ❑I POLYETHLENE WRAP ®2 TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, UIF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTI, A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C,MA•IERML A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED OhTE-LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? DYES ❑NO <br /> THIS FORM ,AS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APP)!CANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL'A Y USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK IQ# <br /> ,t <br /> Gf <br /> [PERMIT <br /> RENT LOCAL A49HCY FACILITY Ip# APPROVED BY NAME <br /> EIII=r [T4 <br /> -� 6 �,/ PHONE#WITH AREA CODE <br /> NUMBER PERMIT APPROVAL DATEPERMIT EXPIRATION DATECK# PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT# BY: <br /> FORS a(6-29,--N) THIS FORM MUST BE ACCOMPANIED FACILIT1f/SITE APPLICATION, <br /> FORM'A',UNLESS A NT FORMA' NAS BEEN FILED <br /> DATA PROCESSING COPY <br />