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%7 1 A I C Vr 40AL111-V rtollA WATER RESOURCES CONTROL BOARD FORM V: / / UNDERGROUND STORAGE TANK PROGRAM TANK l/ TANK PERMIT APPLICATION INFORMATION % COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ MANENTLYC 0 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT [:]6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O yy FACILITY/SITE NAME WHERE TANK IS INSTALLED: P A-Vf, FARM TANK-YES❑ NO •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS �1-IF UNKNOWN—SO SPECIFY � � 9�-3 b A. OWNERS TANK ID N B. MANUFACTURED BY: W C.YEAR INSTAL D b D. TANK CAPACITY IN GALLONS: II. TANK 96NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CST A, [Ef 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 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 C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF ❑ 1MJIILE WALLED ❑ 3 SINGE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELPRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑ ❑9 BRONZE ❑ 10 GALVANIZED ❑ 95 UNKNOWN 99 OTHER C.INTERIOR ❑ I RUBBER UNE ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PM UNING LINING ❑5 GLASS UNING ❑6 UNLINED NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE E&IruNKNOWN ❑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 U 95 UNKNOWN A U 99 OTHER S.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 STEEL CLAD W/FRP A U B IOD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P 6 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 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 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN (ALLOW 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID S CURRENT LOCAL AGENCY Fppg�ILITY IDN APPROVED BY NAPE PHONE N WITH MG CODE W6 GFl b S 1^/ 0 PERMIT NUMBER PERMIT APPROVAL DATE PERU EXPIRATION DATE —/ 11G� CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT/ ST; FORM B(6.29-w) THIS FORM MUST BE ACCOMP 1 BY A FACILITY/SITE APPLICATION, FORM `A',UNLEa, -:URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY