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STATE OF CALIFORNI WATER RESOURCES CONTR( 30ARD FORM V: UNDERGROUND STORAGE TANK PROGRAM Y`'= TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 015 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I� FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IG A. OWNERS TANK ID# B. MANUFACTURED BY: aulk-1 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 000 CA) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 41 h A. i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM BC. Er1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT F-] 4 OIL Fri-PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS L]80 EMPTY [-]95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) f D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.OVA All. TANK CONSTRUCTION MARK ONE ITEL ONLY IN BOX A,B,C,8 D { A. TYPE OF ❑ 1 UBLE WALLED ❑ 3SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 52ri-STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ T ALUMINUM ❑ 8100%METHANOL COMPATIBLE ERP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING C. INTERIOR LINING F-15 GLASS LINING ©6 UNLINED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYEIHLENE WRAP 2TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U W OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE - A U 7 STEEL CLAD WEEP 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 S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S PRECISION TESTING P S I PRESSURE TESTING P S 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 OU TI OF 3 WAST ,I LED WITH SUBSTAN MA *IN GALLONS IAL? _]YES ❑ NO THIS FORM HAS BEEN GOMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED E IS TRUE AND CORRECT. I APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® D D 1 3 0 6 CURRENT LOCAL AGENCY FACILITY ID`� APPROV BY NAM PHONE#WITH AREA CODE M Zs PERMIT NUMBER PERMIT APPROVAL DA RMIT %PIMTION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-eel THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM `A',UNLESS A{.�1 TIRENT FORMA' HAS BEEN FILED - DATA RROCESSING COPY