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WATER RESOURCES CONTPF--POARQ LIQ D&GROUND STORAGE 'T'ANK Rp";RAM TitNK TANK PERMIT APPLICATION INFORMATION COMPLETE A SCI"%zRAT£FORM WITH THE FO!_LOWING INFO!'P,'.'':TION FOR F_ACH TANK. :C `.jI MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT �!� 5 CHANGE OF INFORMATION � 7 PERMANENTLY CL ^� ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITi NAIVE WHERE TANK IS INSTALLED: lS � �h FARM TANK-YES D NO C: t. TAN'' n-ESC^I?TI^IV COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY _ Q A. OWNERS TANK ID 9 G QCT{�(�� I L. MANUFACTURED BY: IIA C C. YEAH INSTALLED U D. TANY,CAPACITY IN GALLOP S: I e9(9n am It. TAN"CONTEE+QTS IF(A.11,IS MARY.FD,C07PLETE ITEM C.;!:(A.1),IS NOT PARKED,COMPLETE ITEM D. �. r— a I C. 1 UN'[A(`ED LEADED D!LSEL A. ❑� 1 MOTOR VEHICLE FUEL ❑� 2 PETROLEUM ❑ ❑� ❑I 3 CHEMICAL PRODUCT L_i 4 OIL C T ODUCT I [7 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 1 ❑5 HAZARDOUS 80 EMPTY E] 95 UNKNOWN 1 ❑ 2 WASTE ❑ 7 METHANOL LF- 1 99 OTHER(DESCR'BF IN ITEM D,BELOW) D. IF NOT MOTOR.VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.N: i TANK r.',3N'c;TPUCT!r-)N MARX ONE ITEM ONLY IN POY A,P.C,A D f A TYPL OF ❑ 1 DOUQL F WALLED U 3 SINGLE WALLED WITH EX1 ERIOR LINER 95 UNKNOWN i SYSTF.`a'. ❑2 SINGLE WAL IIED ❑4 SECONDARY CONTA!NYENT ❑ 99 OTHER i ( ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIP'9GLASS REINFORCED PLASTIC R.TANK i ❑�5 CONCRETE ❑I 6 POLYVINYL CHLORIDE ❑7 ALUMINUM P.100%METHANOL COMPATIBLE FRP I RE.ATERIAi I 1 ❑9 BRONZE (❑ 10 GALS".Y!ZED STEEL �j(�95 UNM,NOWN E] 99 OTurR F-11 RUBBER,LINED ❑2 ALKYO LINING F-1 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR UPING ❑ 5 GLASSIINING ❑6 UNLINED y95 UNK,NnWN ISLININGMATERIALCOMPATIKL WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORPOS!ON ❑ 1 POLYETHLENF WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTEGT!OY ❑5 CATHODIC PROTECTION ❑91 NONE >—?i,95 UNK,NC',% ❑ 99 OTHER 'Y. PIPING-. 1V-'ORMI ATION' CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE P_SYSTEM TYPE U t SUCTION A U 2 A U 3 GRAVITY A U 91 NONE A U -LU ':OWN A U 99 01`iER B. COI MSTRUCTIOM A U 1 SINGLE WALLED A V 2 DOUBLE WALLED A V 3 LINED TRENCH A U 91 NONE h' AU 99 OTHEI-1 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIOF(PVC) A U 4 T(i:tllchc557IPE A U 91 NONE C.MATER '-% A U 5 ALUMINUM �,'-t -I 5 CONCRETE A U 7 STEEL CLAD W1 FRP A U 6 100%METHANO'_COMi'A I IBLE FRP i jA U 9 GALVANI7ED STE! n Lf•- _ NKNOWN A U 99 OTHER i Y. LEAK V'7 ECTION SYSTFM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST rF CIRCLED. pP S 1 VISUAL CHECK P S 2INVENTORY RECONCILIATION P S 3 VA!)OSEWELL" _S_ 4 ELECTRONICMONI'TOR P 3 5 WiOUNDWATrpVCIN:IC IN(N WELLS I 6 PREC'4!ON TESTING P S 7 PRESSURE TESTING P S 97 NONE /p UNKNOWN —S 99 OT I'.ER YI. INFr RIPPATIOM ON TAhM PlIM MANI'A'TLY CLOSED IN !'-ILACF F ��1.ESTIVATED TE LAST U S'-D(MO/YR) 2. FFT!MATEO OUANT^�OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN O INERT MATERIAL? ❑YES (/�,i NO ��iiii rALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTYURY,AND TO THF ST OF MY KNOWLEDGE,IS TRUE AND CORRECT. A?PL!CAN-;S NAM':(PHIN'ED 8 S TUBE) ) b Flifte'll— LOCA'- AGENCY USE ONLY E• CO':