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STATE OF CALIFORNIA WATER RESOURCES CONTRA BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION Go COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CU96"K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /S FACILITY/SITE NAME WHERE TANK IS INSTALLED: S FARM TANK-YES❑ NO ErZ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (C A. OWNERS TANK ID If D-2—, 1 B. MANUFACTURED BY: yl C. YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: 000 W IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. - 1 MOT OR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL �t PROOUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 8 AVIATION GAA ❑ 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 ,L HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.B.#: 4 .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM [CK2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEBUIRDN ❑2 STAINLESS STEEL ❑ 3 RBERGU38 ❑ 4 STEEL CLAD W/F18ERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLOFIDE ❑7 ALUMINUM ❑8 IOAMETHANOLOOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER [:] 1 RIBBER UNED ❑ 2 ALKYD UNING F-13 EPDXY LINING ❑ 4 PHENOUCUNING C. INTERIOR LINING ❑5 GLASS UNING ©6 UNLINED ❑95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPIOTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB VE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U1 SINGLE WALLED A-5 2 DOUBLE WALLED A U 3 UNEDTRENCH 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 C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 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. /'-7 P VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS \J P S PRECISION TESTING P S ] PRESSURE TE3TING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED D TE LAST USED(MO/YR) 2. ESTIMATED QUANT OF 3.WASTAN 61 LED WITH SUBSTANCE E IN INE IAL? ❑YES ❑ NO , GALLONS THIS FokM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# d 1 3 TI -71 1010101 CURRENT LOCAL AGENCY FACILITY 1D M -� APP ED BY NA E PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL ITATt ERM EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIER nY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS At%RENT FORM'A' HAS BEEN FILED OATA,PROCESSING COPY