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STATE OF CALIFORP' & WATER RESOURCES CONT 90ARD ".:^ ` FORM V: UNDhGROUND STORAGE TANK PROMRAM � TANK TANK PERMIT APPLICATION INFORMATION '�§_ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- - L MARK ONLY ❑/ NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 RMANENTLY CLOSE/' ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE B TANK REMOVE�Q 7 CA FACILITY/SITE NAME WHERE TANK IS INSTALLED: CjJ �_ FARM TANK•YES NO ❑ h-1 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Of A. OWNERS TANK 10 M i B. MANUFACTURED BY: F\ C. YEAR INSTALLED Vic I D, TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. V A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑I PRODUCT ❑ 4 GASAAHOL ❑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 6 C A.S.M C.A.S.M 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.S.C.A D A TYPE OF ❑ I DOUBLE WALLED ❑3 BNOE WALLED WITH EXT AM LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMEM ❑99 OTHER ❑ 1 STEELRON ❑2STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGIAS3 REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL MORIDE ❑7 ALUMINUM ❑B IOB%METHANOLCOMPAnBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER 'r ❑ I RIMMLWM E]2 AlMUNING E]3 EPDXY UMNG ❑4 PHENOLIC UMNG O INTERIOR 5 GUSSUMNG6UNLINED 95 UNKNOWN LINING ❑ ❑ ❑ ❑IS UK/G MATERIAL COMPATIBLE WITH 100%1AETHANOLY ❑YES ❑NO ❑99 OTHER F ORROSION ❑ 1 POLYEIFAENEWRAP ❑2 TAR OR ASPALT ❑3WM'LWRAP ❑4 FIBERGLASS REINFORM PLASTIC ROTECTION ❑5 GINODICPHO7ECTION ❑91 NOW ❑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 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 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 810 METHANOLCOMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U W OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. • S 1VISUAL CHECK P S 21NVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 9ELEGTRONK:MONITOR I S SGflWND WATER MONITORING WELLS P S I PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 3 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,IS TRUE AND CORRECT. Imo. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY D JURISDICTION R AGENCY Y FACILITY ID B TANK IO 3 CURRENT LOCAL A F CLLT'10T1 APPROVED BY NAME PHONE P WITH AREA CODE y PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 9-- CHECKS PE FTAMOUNT SURCHARGE AMT. FEE CODE RECEIPTS BY: FORMS(6-29JB® ) THIS FORM MUST BE ACCOMP... -D BY A FACILITYlSITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' RAS BEEN FLEEjD(�