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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. Z LO MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOSED T NK ONE ITEM 2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE EP<TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A A. OWNERS TANK ID R 3 ---4:;.-. B. MANUFACTURED BY: C. YEAR INSTALLED L< D. TANK CAPACITY IN GALLONS: IL TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑3 CHEMICAL PICLE RODUCTL ❑ 4 OPETROLEUM B PRODUCT C ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 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&C.A.S.R C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �2esNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 5TEEUIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS F-14 STEEL CLAD W/FI8ERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORDE ❑7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑MOTHER C. INTERIOR ❑ I RUBBER UNE ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑�14 PHENOLIC LINING LINING F-15 GLASS LINING ❑6 UNLINED L.t . UUNKNOWN ❑ ISUNING MATERIAL COMPATIBLE W4TH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ T POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINY P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 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 U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A i STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 8 CONCRETE A U 7 STEEL CLAD W/FRP A U 81 DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 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. �l{� P S 1 VISUALCHECK P 5 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P $ 5 GROUND WATER MONITORING WELLS F/A1-�v 1' \ P 5 6 PRECISION TESTING P 5 Z PRESSURE TESTING $ 1 NONE P 5 95 UNKNOWN P $ 99 OTHER VI. INFORMATION ON TANK PERMANENTL CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH OALLONB SUBSTANCE REMAINING IN INERT MATERIAL? F]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION k AGENCY p FACILITY ID M TANK ID R V) v 1010101 CURRENT L CAL AGENCY FACILITY ID� APPROVE BY NAM �O'�.I� PHONE P WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE bERMIT EXPIRATION DATE C CK M PERMIT AMOUNT _SURCHARGE AMT. FEE CODE RECEIPT N BY: �, FORM a(5-29-551 THIS FORM MUST BE ACCOMPANIED'BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY