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STATE OF CALIFORNI WATER RESOURCES CONTRC' {OARD � FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION �/� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.� _ 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK i ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED f FACILITY/SITE NAME WHERE TANK IS INSTALLED: `j FARM TANK-YES NO ❑ W N 00 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—BO SPECIFY L" I A. OWNERS TANK ID p1]4 B. MANUFACTURED BY. U� i C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.11),13 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 'B. C. ❑ I UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL ❑ I PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS i ❑5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) I D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED d C.A.S.p C.A.S.p: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B.C,A D ) A TYPE OF ❑ 1 DOUe1EWALtID ❑3SINGLE WAUUEDWITH aTERMLOO uNKNaWx a SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 B.TANK F-1I STEEL/IRON ❑2 STAINLESS STIR F]3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED FUSTIC I MATERIAL r75 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALU M ❑B 109%METHANOL COMPATIBLEFRP E]9 BRONZE ❑ 16 GALVANIZED MR 95 UNKNOWN ❑99 OTHER t ❑ C. INTERIOR 1 RUBBER UN® ❑2 AM UNING ❑3 RM LINING ❑4 PHBIOUCUMNG LINING ❑ 5 GLASS LINING ❑6 LIMNED UNKNOWN 1 ❑ IS LINING MATEI•MComPATIBLEWITH t00%METMNOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYEIHBEWRAP ❑2TAR OR ASPHALT ❑WRAP a 4 FIBERGLASS REINFORCED PLASTIC E]PROTECTION 5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN 99 OTHER 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 A UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEO TRENCH A U 91 NONE U 95 UNKNOWN A U >A OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A CONCRETE A U 7STEELCLADW/FRP A U 6160%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(" U 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 S ' VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE 8 ' ELECTRONIC MONITOR ■ S 5 GROUND WATER MONITORING WELLS P S I PRECISION TESTING P S 7 PRESSURE TESTING P B 91 NONE P B % UNKNOWN P S %OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2 ESTIMATED OUANTRY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN ONE INERT MATERIAL? ❑YES ❑NO GALL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N AGENCY* FACILITY ID p TANK ID pCol f = = = o go5o CURRENT LOCAL AGENCY FACILITY I • APPROVED BY NAME pNO •Wlill AREA CODE � � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DA7I CHECK N PERMIT AMOUNT £ TGE AMT. FEE CODE REG BY FORMB(6-29-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED