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STATE OF CALIFORNS WATER RESOURCES CONTFO BOARD FORM V: p � UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CUC—SEQ TANK 10 ONE ITEM ❑2INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO lO 3 � Scc��1.5 N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY P A. OWNERS TANK IDA B. MANUFACTURED BY: CJ1 C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEMA. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 ROLEUM R. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICALPRODUCT 4 OIL ❑ 1 PRO CT ❑4 GASAHOL ❑ 5 JET FUEL ❑ fi AVIATION GAS E] 5 HAZARDOUS ❑BO EMPTY [:]95 UNKNOWN ASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.A (,✓4 5 oI a s��- C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 O A TYPE OF ❑1 DOOMWALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 OWN SYSTEM ❑2SNGIE WALLED ❑ 4 SECONDARY CONTAINMENT 990THEfl �X �`"'�- ❑ I STEEVIRON ❑2 STAINLESS STEEL ❑3 Fl9ERG ❑ I STFFLCUD W/FIBERGLASS REINFORCED FUSTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 INUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 A1KY0 LINING ❑;P/WOXYD ING ❑ UC LINING LINING ❑5 GLASSUNING ❑ 6 UNUNED UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ NO ❑ 99 OTHER D.CORROSION [7 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALTVI WRAP ❑4 FlBERGUSS REINFORCED PLASTIC PROTECTION ED CATHODIC PROTECTION E:]91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSUFIE A U 3 GRAVITY A U 91 NONE A95 UN 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 95A U 99 OTHER A U 1 STEEL/IRON A U 2 ST INLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 8 WNC RETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A NKN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P OR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 3 1 VISUAL CHECK P S 2 INVENTORY RECO ILIATION P 3 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 9 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S ] PRESSURE TEST G P S 91 NONE P 9St1R O P B 99 OTHER VI. INFORMATION ON TANK PERLYiNENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF 1 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [_-]YES ❑ NO THIS FORM HAS BEEN COMPLEIED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINT &SIGNATURE) DATE LOCAL AGENCY USE O LY COUNTY A JURIS&CTION A AGENCY A FACILITY ID A TANK ID A 1010101 S CURRENT LOCAL AGENCY ACILITY ID• APPROVED BY NAME PHONE•WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT RCHARGE AMT. FEE CODE FORM B(6-29-Bfi) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY