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STATE OF CALIFORNI` WATER RESOURCES CONTRq&OARD FORM V: UNDERGROUND STORAGE TANK PROGRAM Qp TANK TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 1 MARK ONLY F-11 NEWPERMIT [--13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION [-] 7 PERMANENTLY CLOSED TANK O ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSUREANK REMOVED OQ W � IH 49-- o-TL -n 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: J - C- FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERS TANKID# B. MANUFACTURED BY: OD C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: -J II. TANK CONT NTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. -IMOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS E]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&C A.S.# C.A.S.#: _ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINEA 95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRGN 2 STAINLESS STEEL F-�3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-1 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL UNKNOWN 99 OTHER C. INTERIOR F--] 1 RUBBER LINED ❑2 AUKYD UNING F-]3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED C24'�UNKNOWN ❑ ISUNINGMATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO HER (,^A &f- D. f .D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑ 3 YPYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHOOIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICA13LE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE U 5 UNKNOWN A U 99 OTHER 8.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 5 UNKNOWN A U 99 OTHER A U 1 STEELPFION 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 /L��6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A/U 195 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 IVISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P' S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/ 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY C'OU)IrnNTTY'Il# JURISDICTION# AGENCY# FACILITY ID# TANKID# Il - CURRENT LOCAL AGENCY FACILITY ID p V`s APPROVED BY NAME 1 - ) l � 9#WITH AREA CODE 1 11W/7 /Vo PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT RCHARGE AMT. FEE CODE CEIPT# BY: of 7 FORM R(6-2966) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORM W HAS BEEN FILED DATA PROCESSING COPY