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:Tam. p�t. w1r �M�• --n+ , 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. - Z 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDT ONE ITEM El INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: S, G,gi-J7f a FARM TANK-YES❑ NO (a I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O N A. OWNERSTANKID# I I B. MANUFACTURED BY: co C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED EK DIESEL [--1 3 CHEMICAL PRODUCT ❑4 OILRODUCT ❑4 GASAHOL ❑ 5 JET FUEL E:] 6 AVIATION GAS E]5 HAZARDOUS ❑80 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 8 CA.S.# C.A.S.#: III. TANK CONSTRUCTION NARK ONE ITEM ONLY IN BOX A B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT Z 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL 3 RBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑810M METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING JI LINING LINING F-15 GLASS LINING ❑6 UNLINED � UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MERIANOL7 ❑YES El NO F OTHER 0 CORROSION F-1 I PROTECTION ❑5 CATHODIC PRONE TECTION ❑91TAR OR NONE ASPHALT 95 UNKNOWN ❑99 OTHER SS REINFORCED PLASTIC IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE AU 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE LL WAED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A:D\a CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A V U 95 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. OL2 8 1 VISUALCHECK P 3 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S fi PRECISION TESTING 3 ] PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MONR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® � I olol Io iSaaCODE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH APERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECK# PERMIT AMOUNT -SURCHARGEAMT. FEE CODE RECEIPT# BY: FORMBB-29-88) THIS FORM MUSTBE ACCOIWANIED BYA FACILITY/SITE APPLICATION, FORM `A',UNLESS AZIiRRENT FORMA' HAS KEEN FILED DATA PROCESSING COPY