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I Alt OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION �o COMPLETE ASEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. '. .. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY-C/L •„K 1:1 ONE ITEM 2 INTERIM PERMIT ❑ p AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEyQ C FHyy FACILITY/SITE NAME WHERE TANK IS INSTALLED: G� �� a9/� gam fQ/L,�'c FARM TANK-YES /❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SD SPECIFY /ILZ°� Q rJ`j� - •� A. OWNERS TANK ID p B. MANUFACTURED BY: S CTJ / W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED OMPLETE ITEM D. µ A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. I UNLEADED) ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑p OIL ❑ ❑5 JET FUEL ❑fi AVIATION GAS 1 PRODUCT p GASAHOL ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.p C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑A SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 8.TANK 1 STEEUIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS A STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIOE ❑ 7 ALUMINUM ❑ B 1011%METHANOL COMPATIBLE FLIP ❑9 BRONZE ❑ 10 GALVAMZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑2 AL KYO LINING 3 EPDXY LINING ❑A PHENOLIC LINING LINING ❑5 GLASSUNING ©6 UNUNED ❑ 95 UNKIIOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑p FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHOOICPROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE ECONSTRUCTION YPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED THE A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL71RON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FHP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER A U 81001 METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 6 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P B D) ELECTRONIC MONITOR PP 8 6 PRECISION TESTING P 6 7 PRESSURE TESTING g 5 GROUND WATER MONITORING WELLS P 5 9/ NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY Of SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH GALLONg INERT MATERIAL? yEg ❑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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY e COUNTY# JURISDICTION 0AGENCY# -n FACILITY ID p TANK ID p CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE I WITH MEA CODE PERYIT NUYBEq C PERMIT APPROVAL DATE PEgY1T EXPIRATION DATE CHECK# PERMITAMOUNT eURCMARGE ANT. FEECODE RECEIPT# BY: FORM B(6-2906) THIS FORM MUST BE ACCOMPANIED Y A FACIUTYISITE APPLICATION, FORM 'A',UNLESS Aa/RRENT FORM W HAS BEEN FILED DATA PROCESSING COPY