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STATE OF CALIFORNJ& WATER RESOURCES CONTRBOARD ,{ FORM V: UNDINGROUND STORAGE TANK PR*RAM ` TANK PERMIT APPLICATION INFORMATION 3 TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. --- z 90 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 P MANENTLYCLO TO TANK. ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED )OIL FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO W 01 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECT Q') A. OWNERS TANK ID# B. MANUFACTURED BY: u C.YEAR INSTALLED 0. TANK CAPACITY IN 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 FU ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑8 PTY ❑95 UNKNOWN F--] 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NA OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITE NLY IN BOX A.B,C,8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WAN95 INER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDAR ❑99 OTHER ❑ 1 STEEL/IRON ❑25TAINLESS FIBERGLASS ❑ dSTEEL CLADWIFIBERGVSS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLINUM ❑810A METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZ [E:] 5 UNKN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD LINIEPDXY LINING 4 PHENOLIC LINING C. INTERIOR 5 GLASS LINING 6 UNUNED 95 UNKNOWN LINING ❑ ❑ ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ THER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERG 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 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 A U NKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE PVC) A U d FIBERGLASSNkA U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL PATISLE 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 P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 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/YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT 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# 06 a � ool CURRENT CAL AGENCY FACILITY ID# APPROVED Y NAA1 PHONE#WITH AREA CODE JPERMIT NUMBER PERMIT APPROVAL DATE P/ERM EXPIRATION DATE CXECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: FORMBT6,29[-88) THIS FORM MUST BE ACCOMPANIE!SYA FACILITY/SITE APPLICATION, FORM 'A',UNLESSAwJflENT FORMA' HAS BEEN FILED DATA PROCESSING COPY