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STATE OF CALIFORN' WATER RESOURCES CONTRO'",OARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSU//R��E11 8 TANK REMOVED1 Loll FACILRY/SITE NAME WHERE TANK 1E INSTALLED: '7Q O I /..J f} A y-A FARM TANK-YES NO 1. TANK DESCRIPTION COMPLETE ALL nIT-EMS-IF UNKNOWN-SO SPECIFY A. OWNER$TANK IDN / B. MANUFACTURED BY: C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: 42 II. TANK CONTENTS (Al),IS MARKED,COMPLETE ITEM C.IF(A/),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑A OIL ❑ 1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑SO 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 8 C.A.S.N CA.S,N. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A B,C.A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WT01 EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONDARY CONTAIN MEM M OTHER �1 STEELIAON ❑2 STAINLE%STEEL ,❑3 FIBERGLASS ❑A STEEL CLAD WIFIBERGUS6 REINFORCED F,ARTIC S.TANK MATERIAL F-15 CONCRETE El6 POLYVINYL CHLORIDE ❑7 ALLABNUM ❑8 IW%MErHWL COMPATIBLE FRP ❑9 BRONZE ❑ iD GALVANIZED STEEL ❑%UNKNOWN ❑99 011RER ❑ I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑1 PHENOLIC LINING C INTERIOR6 UNLINED %UKNOMN LINING ❑S GLASS LINING ❑ ❑IS LINING MATERIAL COMPATIBLE WITH 1031E METHANOL' ❑YES ❑NO ❑99 OTHER D.CORROSION ❑I POLYETNFM WRAP ❑2 TAR OR ASPHALT 3 VINYL WRAP ❑1 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 95 UNKNOWN A U "OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVCI A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 81 DD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 11095 UNKNOWN A U N OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. [ IWSUALCMECK P B 2 INVENTORY RECONCILIATION P t 3VADOSE WELLS P 6 A ELECTRONIC MONITOR ■ S 5 GROUND WATER MONITORING WELLS [ 6 IRECISION TESTING P B 7 PRESSURE TESTING P S 91 NONE ('P)S 95 UNKNOWN I S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OFGALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑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&SIGNATURE)` DATE T f LOCAL AGENCY USE ONLY COUNTY N JURISDICTION I AGENCY N FACILITY ID F TANK ID S ® = I I I I p o II Az ol o I o / CURII[NT LOCAL AGENCY FACILITY IO N APPROVED BY NAME PHONE F WITH AREA CODE ►E11YR NUMBER PERMIT APP110YAL DAT[ P[RYR EXPIRATION DATE 1 /41-/g-90 CHECK F PERMIT AMOUNT SURCHAAGE ANY. FEE COD[ R[ttIPT I BY- FORMB(e"29-MI THIN FORM MINTEEACCWAIV-`T AFACEITTAIMAm LUTON. FORMIA',LK=Ar -91T PM-N IMSSEENFK.ED 1 DATA 11"CESSING COPY 2 LOCAL AGENCY Cow "t RLE COPY `\I