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STATE OF CALIFORNI, WATER ESO RIWSb.64-oP7Y-ni4S C-ON4 Rel.. ep� FORMV,, UNDERGROUND STORAGE TANK Pael, TANK / TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. •u' o MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PCRMIT CHANGE OF INFORMATION C] 7 PERMANEN"1 LY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT U 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: '��y U j 3- � FARM TANK-YES u NO •a I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID q t1k B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: f,Ue) •� .� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. IL ( A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL Ea KiPROOUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS i ❑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.#: i III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF J2'*'SIONGLE UBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER F--] 95 UNKNOWN SYSTEM WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F] I STEELPRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE 7 AIWINUM ❑8)OR METHANOL COMPATIBLE FRP ❑9 BRONZE E:]10 GALVANIZED STEEL 5 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED F-12 ALKYD LINING F-13 EPDXYLINING ❑4 HENOLIC LINING LINING C.INTERIORF-15 GLASS LINING E-16 UNLINED �9ONKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 1D0%METHANOL? ❑YES NO 99 OTHER i D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT R9'5tNKNOWN WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION ❑91 NONE ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE: A.SYSTEM TYPE A U 1 UCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 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 fi5 UNKNOWN A U 99 OTHER - A U 1 STEEL/IRON 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 A6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER - V. AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P 3 7 I'IESSURE TESTING P i9 91 NONE P S 95 UNKNOWN P S 99 OTHER i VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFNS 3.WAS TANK FILLED WITH GALLO SUBSTANCE REMAINING IN 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 i - LOCAL AGENCY USE ONLY COsU INT�Y# JURISDICTION# AGENCY N FACILITY ID M TANK ID N CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 0 PERMIT AMOUNT SURCHARGE AMT. FEE CODE 1 RECEIPT k BY: /�/��