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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK �iCOMPTANK PERMIT APPLICATION INFORMATION 'y % LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T K ONE ITEM ❑2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED a FACILITY/SITE NAME WHERE TANK IS INSTALLED: S BAT .� FARM TANK-YES❑ NO / I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY / s •O A. OWNERSTANKIDB B. MANUFACTURED BY: PE/GK/n/S W C. YEAR INSTALLED g D. TANK CAPACITY IN GALLONS OC D rj II. TANK P16NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM D. A I MOT OR VEHICLE FUEL ❑ 2 PETROLEUM B. C. gall UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ A OIL Eff 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 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 6 C.A.S.N C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,i D A TYPE OF ❑ WALLED ❑3 SINGLE WALLED MTN EXTERIOR LINER F-195 UNKNOWN SYSTEM 2 SINGLE WALLED ❑A SECONDARY CONTAINMENT 99 OTHER I STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑/STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑1 ALKYD LINING ❑ 3 EPDXY LINING LIC LINING G INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED Lff"KNOWN ❑ IS UNING MATERIAL COMPATIBLE MTH 100%METFW O ❑YES ❑ NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑ 3 VIN�YLWRAP ❑/RBERGLASSREINFORCEDPLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 5A-UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A WI SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 8.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A Ct5 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U < FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE AU 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 5 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 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S I ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS b rI P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO OALLONB THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION B AGENCY E FACILITY ID E TANK ID R = = = 1 U49 1 1 1511 16 C-/ 1,-) 1/ L CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE F WITH AREA CODE 0 V5 E7 If I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRATON GATE CHECK? PERMIT AMOUNTSURCHARGE AMT. FEE CODE RECEIPT? BY: FORM B(6-28-88) THIS FORM MUST BE ACCOMPAWu BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED - nATA DRYSCc QcIMn .•nom„