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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD " FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT r-] 3 RENEWALPERMIT CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED TAN9 ONE ITEM❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /5 FACILITY/SITE NAME WHERE TANK IS INSTALLED: I!� FARM TANK-YES❑ NO 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# (.. B. MANUFACTURED BY: U j C. YEAR INSTALLED ('�2 D. TANK CAPACITY IN GALLONS: W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A./),IS NOT MARKED,COMPLETE ITEM D. (V A. 1 MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. ❑ 1 UNLEADED DED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 EMPTY [:] 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / HAZARDOUS SUBSTANCE STORED&CA.S.# N C.A.S.#: .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER -1 3 FIBERGLASS 4 MEL CLAD REINFORCED PLASTIC N IECE B. TANK MATERIALF-15 CONCRETE 6 POLYVINYL HORIDE F-1 7 ALUMINUM 8 100%METHANOCOMPLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER U14ED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING I, LINING ❑5 GLASS LINING ❑6 UNLINEDKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10MMETHANOL? ❑YES10 ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL P ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A WABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 9 OTHER Id c)ti B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL 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/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 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 1(YV'J P 5 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 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES El N07 1 �V OALLONB THIS FOR HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE I LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# G lo I z FlS o © o CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE NWITH AREA CODE 4HMPERMIT NUMBER PERMIT APPROVAL DATE MIT PIRATION DAHECKNPERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: a 13-7-eel THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A cu„„RENT FORMA' HAS BEEN FILED CESSING COPY