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STATE OF CALIFORN WATER RESOURCES CONTRI&OARD FORMV:: UND GROUND STORAGE TANK PRO RAM m TANK TANK PERMIT APPLICATION INFORMATION > COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ,FOA N.P. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED �I FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 s�v ifjdlIe FARM TANK-YESF-1 NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN ,tik I B. MANUFACTURED BY: ) C. YEAR INSTALLED D, TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ S CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESC IBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# G.A.S.#: xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELIIRON E] 2 STAINLESS STEEL F-] 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL B.TA ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑ 8 100%MFTHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED F-] 2 ALKYD LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED �95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE �95 UNKNOWN ❑99 OTHER' IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 0 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FAP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER VV.. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ,�1,f P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS U f f� P S PRECISION TESTING P S 7 PHESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V 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 GALLONS INERT MATERIAL? ElYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COU NTY # JURISDICTION# AGENCY# FACILITY ID# �j TANK ID# Ll 1 -1 El I I I- 1 o VQ 0 � � - o a f CURRENT CAL AGENCY FACILITY APPROVED BY NAME PHONE N WITH AREA CODE � LMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE { CK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM R(3-7-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY