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STATE OF CALIFORNIA WATER RESOURCES CONTROARD FORM V: UND ROUND STORAGE TANK PRO AM ' TANK TANK PERMIT APPLICATION INFORMATION G° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOS TANK ONE ITEM ❑2 INTERIMPERMIT Q4-AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: U0D&e.14w1-' FARM TANK-YES❑ NOPr 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# d I B. MANUFACTURED BY: C. YEAR INSTALLED IQ13 D. TANKCAPACITY IN GALLONS: 12,1600 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D tV A. VI MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT F-] 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JETFUHL ❑ 6 AVIATION GAS ❑ 5 HAZARD" L❑ 80 EMPTY [:] 95 UNKNOW 2 WASTE ❑ 7 METHANOL ❑ 99 OT11EiR(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# CV I C.A.S.#: A XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEA ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT, l� ❑ 99 OTHER �� 1 STEELPRON ❑2 STAINLESSSTEEL FIBERGLASS ❑ 4STEEL CLAD W/FIBERGLASS REINFORCED ., C B. TANK S CONCRETE ❑6 POLYVINYLCHLORIDE y I d2hDIMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL �; e(5 ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RU8BERUNED ❑ 2 KYDUNING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING I C. LIH NflGIOR ED GLASS LINING 6 UNLINED ❑95 UNKNOWN 1 j ❑ IS LINING MATERIAL COMPATIBLE WITH 1DG%METHANOL? ❑,YES P NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTI,JN'.) 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- Aa 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION Aro 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AO 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. 1 1 P S 1 VISUAL CHECK Q S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P M 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE ATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TA K,PILLED WITH SUBSTANCE REMAINING IN IN RIAL? ❑YES ❑ NO GALLONS THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND T6 THE BEST OF MY KNOWLE GE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3q = = 10 10 1 116 3 i 0 1 0 1 o CURFEW LOCAL AGENCY gACILITYID# AP D YNAME PHONE B WITH AREA CODE PERMIT NUMBERIlli/ P RM TAPBPROVAL DATE PERMIT EXPIRATION DATE CHECKM PERMIT AMOUNT SURCHARGE AMT. �� FEE CODE Ali; CEIPT# BY: \V•Mf FORMB(3-7-88) THIS FORM MUST BE ACCOMPAl YAFACILITY/SITE APPLICATION, FORM`A',UNLESS,..:URRENT FORMA' HASBEENFILED DATA PROCESSING COPY