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STATE OF CALIFORN& WATER RESOURCES CONTRPBOARD FORM V: UNDt GROUND STORAGE TANK PR GRAM y � ' TANK TANK PERMIT APPLICATION INFORMATION m 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 CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �AjFARM TANK-YES❑ NO 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN—SO SPECIFY O A. OWNERS TANKID# 1�d7f"�t� B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: f W II. TANK C NTENTS IF(A.1),IS MARKED,COMPLEJE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. -J A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL F-13 CHEMICAL PRODUCT ❑ B.4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ((AA ❑ 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOA A,B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM INGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER EUIRON ❑2 STAINLESS ST EEL ❑3FIBERGLASS E]4 STEEL CLAD WIFIBERGLSS REINFORCED PLASTIC S.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100116METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKY LINING ❑3 EPDXY UNING ❑4 PHENOLIC UNING LINING F-15 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAROK LT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-]5 CATHODIC PROTECTION NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNO, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AW STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S PRECISION TESTING P 8 7 PRESSURE TES TING P S 91 NONE- P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS [:]IINERT MATERIAL? ❑YES `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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 6 LPERMITNUMBER LOCAL AGENCY FACILITY ID# APPRO O BY NAME /PHONE#WITH AREA CODE �O PERMIT APPROVAL DA PERMIT E%P ATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE pECEIPT# BY: j Ih FORM B(3-7-aa) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM `A',UNLESS A C..,AENT FORMA' NAS BEEN FILED DATA PROCESSING COPY