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STATE OF CALIFORN` WATER RESOURCES CONTF- BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM !/ TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 RMATION FOR EACH TANK. Z 1 0 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 BKMANENTLY CLO ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ul 6//TEMPORARY TANK CLOSURE STANK REMOVED O w FACILITY/SITE NAME WHERE TANK IB INSTALLED: -✓ ZO� FARM TANK-YES❑ NO ❑ I N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD A. OWNERS TANK IDB 3 1 B. MANUFACTURED BY: CD C. YEAR INSTALLED 6 1 D. TANK CAPACITY IN GALLONS: �Q(� II. TANK CONTENTS IF(A-1),18 MARKED,COMPLETE ITEM C.IF(ACI),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ETROLEUM R. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT 1 OIL ❑DUCT ❑K GASAHOL 5 JET F F-16 AVIATION GAS E]5 HAZARDOUS ❑ 80 EMPTY E]95 UNKNOWN 2 WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.B / C.A.S.B: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S.C.A D A TYPE OF ❑ I DOUNE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNEP ❑%UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEURON ❑ 2 STMNLESSSTEEL ❑ 3 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRE E ❑6 POLYVINYL CHLORDE ❑7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL.. . ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBERLVED E]2 ALM LINING F-13 EPDXY LUNG ❑A PHENOLIC LINING LINING ❑ 5 MASS LUNG ❑6 UNWED ❑95 UNKNOWN ❑ IS LRBNG MATERIAL COMPATIBLE WITH 100%METHNOL7 ❑YES ❑NO ❑ 99 OTHER B.CORROSION ❑ 1 PoLYETHLLIE WRAP ❑2 TAR OR ASPHALT ❑ 3 WNYL WRAP ❑ /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 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 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 U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. P t 1 VISUAL CHECK P t 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P t 6 PRECISION TESTING P t 7 PRESSURE TESTING P t 91 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLON: INERT MATERIAL') ❑YES El 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY F JURISDICTION F AGENCY t FACILITY ID F TANK ID t = s-1 t1 =G-) 3 CURRENT LOCAL AGENCY FACILITY ID B APPROVED BY NAME PHONE 0 W ITN AREA CODE A11691145-1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE a/4 CNECKB PERMIT AMOUNT BURCHAIIGEAMT, FEE CODE RECEIPT BT: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED J