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W ba TATE OF CALIFORA WATER RESOURCES CR�Rp _4131 FORM V: UNDERGROUND STORA 1 ORWALT"6465D TANK TANK PERMIT APPLICAT ii ATION-, COMPLETE A SEPARATE FORM WITH THE FOLLI I d '06k'E•.'AdH TANK. MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED �^ FACILINAME WNERF TANK IS INSTALLED: PCTSITIOT FARM TANK-YES[:] NO TY/SITE 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N WC7706C B. MANUFACTURED BY: CST C.YEAR INSTALLED 1988 D. TANK CAPACITY IN GALLONS: 1,000 gallons 11. 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 FMX� C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑X <OIL ODUCT ❑ GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑W EMPTY ❑95 UNKNOWNASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.M: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOK A.S,C,E D A.TYPE OF X❑1 DOUSLEWALLED ❑3 SINGLE WALLED WITH EXIEROR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑A SECONDAW CONTAINMENT ❑99 OTHER ❑ I STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑/STEELCUD W/FIBERGLASS REINFORCED RAM S.TANK ❑5 CONCItETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METKANOLCOMPATIBUFRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED MEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUSBERUNED F-12 AULYD LINING E]3 EPDXY LINING ❑A PHENOUCUNING C.INTERIOR 5 GLASS UNING 6 UNUNED ❑95 UNKNOWN LINING ® ❑ F-1IS LINING MATERIAL COMPATIBLE WITH 100%METH NOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYEIHLENE WRAP ❑2 TAR ORASRWT ❑3 VIKWRAP ❑A FIBERGLASS REINFOPCEDRASTC PROTECTION ❑5 CATHODIC PROTECTIONX❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U / SINGLE WALLED Ag 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELPAON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U0 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/PRP A U B 1 DD%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 9 1VISUAL CHECK { 2 INVENTORY RECONCILIATION P t 3VADOSE WELLS P 6 A ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS P { 6 PRECISION TESTING P S 7 PRESSURE TESTING P t 91 NONE P t 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YRI 2.ESTIMATED GUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLON{ INERT MATERIAL? ❑YES ❑ ND THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUFDC.AND TH T OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CUI111ENT LOCAL AGENCY FACILITY ID N APPROVED tY NAYS PHONE E WITH AREA CODE CII�VP C7� PNIYRIKIIIBfR PERMIT APPROVAL DALE PERMIT EIWRATON DATE I0�ia�90 CHECKP PERMIT AMOUNT tURCHABDE AMT. FEE CODE RECEIPT E BY: FORM B)6-29.66) THIS FORM MUST K AMOMMONEW A FACETYAREAF1ucATKNL FORM 'A',UM,E FORM A' IMS SEEN FILED A F. 1 DATCESSING COPY 2 LOCAL AGEMCr RLE COPY