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STATE OF CAL0FOFtM0A WATER RESOURCES CONTROL 'ARD FORM V: UNDERGROUND STORAGE TALK PROeRRAM 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 CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: No-3 A/ FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1 Q A. OWNERS TANK ID p B. MANUFACTURED BY: (f� C. YEAR INSTALLED IqwD. TANK CAPACITY IN GALLONS: 300 O W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. --4 A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL r. ❑3 CHEMICAL PRODUCT OIL ER 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS cz) 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 (t)C) HAZARDOUS SUBSTANCE STORED&C.A.S.N O (� �T fr�49rtt x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM �SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER EEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE 7 ALUMINUM 8 10091 METHANOL COMPATIBLE FRP HATERIAL 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED 2 ALKYD LINING E—]3 EPDXY LINING 4 PHENOLIC LINING LINING ❑5 GLASS LINING Eg-E-INUNEO ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 T OR ASPHALT F-13 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION AU 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A el STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A IJ 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER I V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. =b6 CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ON TESTING P S 7 PRESSURE TESTING P S 91 NONEP S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I 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,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION S AGENCY N FACILITY ID 8 TANK ID# F-:7 I I I I I I 1 1-1 1 - I ol / I q I n I—o 1--5� CURRENT LOCALAGENCY F CILITY ID N APPROVED Y NAME PHONE K WITH AREA CODE �OLw 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIOPtDATE CHECK M PERMIT AMOUNT --URCHARGE AMT. FEE CODE RECEIPT M BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED'9Y A FACILITY/SITE APPLICATION, FORM'A',UNLESS AVaRENT FORU'A' HAS BEEN FILED DATA PROCESSING COPY