SITE INFORMATION AND CORRESPONDENCE

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STATE OF CALIFORNIA WATEFtRESOURCESCONTRO& -I kRDt; FORM V: . UNDERGROUND STORAGE"TANK PROGRAM A`N K- TANK PERMIT APPLICATION IN COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR 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 Z FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO g Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I o A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED JAL D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CJ{ A. ❑ 1 MOTOR VEHICLE FUEL ❑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 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OFt HAZARDOUS SUBSTANCE STORED&C.A.S.# jI C.A.S.q: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,s D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ' ❑ i STEEVIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP. 9 BRONZE 10 GALVANIZED STEEL 95 UNKNONRI 99 OTHER f' C. ❑ 1 RUBBER LINED ❑2 ALKYD LINING' ❑3 EPDXY LINING.. ❑ UNW. PHENOLIC UW. INTERIOR LINING F-15 GLASSUNING ❑6 UNLINED X95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 1 D0%MEmwL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑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 1� A U 99 OTHER I" B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 95 UNKNOW A U 99 OTHER 7 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYC i HLORIDE(PVC) A U 4 FIBERGLASS PIPE Ic C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELi2!f777wrowN A U 99 OTHER 1 V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE' 95'uN-Kvqr4 P S 99 OTHER VI. 'INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR)" 2. ESTIMATED QUANTITY OF �'F 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN iiINERT MATERIAL? ❑YES ❑ NO l GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THEIBEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) j DATE LOCAL AGENCY USE ONLY I ,r COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 391 10 i0 r I 'q5 En I o I o ,I _ ,CURRENT LOCAL AGENCY FACILITY ID_N APPROVED BY NAME PHONE#WITH AREA CODE IPERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRATION DATE iCHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: p 'y FORM 0(3-7-68) THIS FORM MUST BE ACCOMPAN604Y A FACILITY/SITE APPLICATION, FORM `A%UNLESS ARRENTFORIVK NAS BEEN FILED DATA PROCESSING COPY ��,.�.:_-__�� -�----,_ -- -' - -. ;:�. .._.-.�„�_�-:-.=ter'--"• ice. ---- -..._ .. --�-- -._ _ ,._ _� __