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STATE OF CALIFORNIP WATER RESOURCES CONTROL ^OARD FORM V: UNDEIrdROUND STORAGE TANK PROUMAM 4 ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY [--1 1 NEW PERMIT F-] 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P HMANENTLY CLOSE K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Oq FACILITY/SITE NAME WHERE TANK IS INSTALLED: S . YL.e�.Qt C,AJ FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I� A. OWNERS TANK ID a 6. MANUFACTURED BY: Uj1.a.�J C. YEAR INSTALLED D TANK CAPACITY IVALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CA A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. i UNLEADED ❑ 2 LEADED Ep"3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL gKPRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑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.a C.A.S.a: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A TYPE OF IIT9y1I� DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM W 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER KT1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYWNYLCHLORDE ❑ 7 ALUMINUM ❑8100%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING EqlfUNUNED ❑95 UNKNOWN ❑IS LINING MATERMLOOMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POIYETHLENEWRAP ❑2 ROR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ON CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A kl SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE I C. MATERIAL A V5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. �yy�6 ,I( P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P^' P S B PRECISION TESTING P S I PRESSURETESTING 1 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LA USED(MO/YR) 2. ESTIMATED QUA TITY OF 3.WASTAN BILLED WITH SUBSTANCITi� LNG IN GALLONS INE AL? ❑YES [—] NO A/1/ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE JURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a AGENCY a FACILITY ID a TANK ID a 3 ` D I o I l 13 = I o c) CURRENT LOCAL AGENCY FACILITY ID a APP O ED 13 ME PHONE a WITH AREA CODE S PERMIT NUMBER PERMD-APPROVALDA PERMIT EXPIRATION DATE \\ CHECK a PERMIT AMOUNT _ _ SURCHARGE AMT. FEE CODE RECEIPT a BY: _V\UI FORM B(3 7-Ra) THIS FORM MUST BE ACCOMPANIORZ FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY