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STATE OF CALIFORN16 WATER RESOURCESCONTROARD ;. FORM V: UND GROUND STORAGE TANK PR RAM w' TANK TANK PERMIT APPLICATION INFORMATION m ti COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT X 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 113EOCD m. \ FARM TANK-YES❑ NO54 O I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ' A. OWNERS TANK ID# u I\ I B. MANUFACTURED BY: u r__ w C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Moo ell 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 L ED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL 7UEL / 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 82 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,A D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM si 2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑ 99 OTHER M-1 STEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBERUNED E]2 ALKYD LINING [__j3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIALCOMPATIBLE TH 100%ME7HANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION R 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFASOVEGROUND, 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 %UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE Pfy 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 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%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 1VISUAL CHECK 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISIONTESTING P S 7 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 QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:jYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# F LITY ID# TANK ID# L14LL q 3 1 1 1 1 1 / CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE#WITH AREA CODE �e-0r -PERMITITUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE II � gj /1I CHECKN PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# By FORM B(6-29-89) THIS FORM MUST BE ACCOMPANIE FACILITY/SITE APPLICATION, FORM `A',UNLESS AWMENT FORMA' HAS BEEN FILED DATA PROCESSING COPY