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STATE OF CALIF0140 IA ,. WATER RESOURCES CON^Oh BOARD FORM V: U ERGROUND STORAGE TANK OGAAM G Y wo TANKTANK PERMIT APPLICATION INFORMATION ` OOMPLETE"A'SEPARATE FORM WITH THE FOLLOWING INFORMATION 009 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 Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK—YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS—IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# 7V7— 1-- B. MANUFACTURED BY: L✓�/[, C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CO TENTS 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. �-{1p[�DED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT 1:14 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑ BO 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.to: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINEA ❑ 95 UNKNOWN SYSTEMP-2-SINGLE WALLED 4 SECONDARYCONTAINMENT ❑ 99 OTHER ❑ 1 STEEI_IIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 IDD%METHANOL COMPATIBLE FRP MATERIAL , ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASSUNING ❑ 6 UNLINED ❑95hfNR QWN. ISLININGMATERIAL COMPATIBLE WITH 100%METHANOL? El YES El NO El 99 OTHER 0.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE 5 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A SUCTION A ,U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 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 95UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL 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 STEEL CLAD W/FRP A U 8 104%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A& 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 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 QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE { LOCAL AGENCY USE ONLY 1 COUNTY# JURISDICTION# AGENCY# FA TANK ID M = I I I- I I 4--L- J - I CURRENT CAL AGENCY FACILITY APPROVED BY NAME PHONE#WiTH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# pJAMOUNT'. —-SURCHARGE AMT. - FEE CODE _R)ECOPT N BY: r FOAM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY,