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STATE OF CALIFORNI WATER RESOURCES CONTROARD Qp FORMV: UND GROUND STORAGE TANK PR RAMTANK 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_P ENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMEND RMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED P77 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO ❑ –�-I L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY / CO A. OWNERS TANK IDR0. MANUFACTURED BY: � C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 477z •-:� f II. TANK CPNTENTS 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. ❑ I UNLEADED ❑2 LEADED 3 DIESEL -13 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAB ❑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 8 C.A.S.R C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNEP E1,95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑TANK I STEEUIRON ❑2 STAINLESS STEEL [:]3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP E]9 BRONZE ❑ 10 GALVANIZED STEEL ❑-95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED E]2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑ NO OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 LWMP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE W 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 .0 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 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 UV C MATERIAL U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 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. VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS NP e 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO7YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY A COUNTY Y JURISDICTION Y AGENCY R FACILITY ID R TANK ID# I d A 1 I 9 I I 0 I 6 I 63 • CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE WITH AREA CODE Ma zz� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTI By;� „� FORM 8(6-29-85) THIS FORM MUST BE ACCOMPANI .AFACILITY/SITE APPLICATION, FORM 'A,UNLESS A CURRENT FORMA' HAS BEEN FILED DATA GDn P9QQ1Mn f`nev