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STATE OF CALIFORNIS WATER RESOURCES CONTRCpARD FORM V: UNDE GROUND STORAGE TANK PRO AM Qp TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF RMATION FOR EACH TANK. z MARK ONLY F-] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION �7 PERMANENTLY CLOSED TANK IO ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: O M p.l N Sr FARM TANK-YES❑ I (,V I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 A. OWNERS TANK ID# B. MANUFACTURED BY: CSI C. YEAR INSTALLED V D. TANK CAPACITY IN GALLONS: 452-57-35 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 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.P: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLEWALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CIAO WIFIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALU ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 AU88ER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINEDNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO [ 99OTHER D.CORROSION ❑ i POLYEIHLENEWRAP ❑2 TAR OR ASPHALT 3 VI P ❑ 4 FIBERGLASS 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 A5 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 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A'U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A<�> 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 5 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USEDWO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH q/1 SUBSTANCE REMAINING IN INERT MATERIAL? ❑YE$ ❑ NO �`� GALLONS THIS FORM HAS BE N 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 IDR TANKID# a3 -3 1 121 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE R WITH AREA CODE Moo a i PERMIT NUMBER PERMIT APPROVAL DATE ER TEXPIRATION E CHECK# PERMIT AMOUNT I SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'k UNLESS A C ARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY