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STATE OF CALIFORNI/v WATER RESOURCES CbNTR RD ". FORM V: UNDERGROUND STORAGE TANK PR61URAM =�` TANK PERMIT APPLICATION INFORMATION -.y TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. - z _ ,o MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOS ONE ITEM [:] 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE E]B TANK REMOVED S W FACILITY/SITE NAME WHERE TANK IS INSTALLED: 33600 1<05,A4, FARM TANK-YES NO ❑ w / t:7 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY o r A. OWNERS TANK ID R B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: A II. TANK CONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A-1).IS NOT MARKED,COMPLETE ITEM D. r A. ❑ 1 MOTOR VEHICLE FUEL 2 PET B C. 0 1 UNLEADED 2 LEADED ❑ 3 DIESEL � V�l 3 CHEMICAL PRODUCT 4 OIL ❑ 1PRODUCT 1-14 GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS 80 EMPTYNOWN 2 WASTE 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) r D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.k: HAZARDOUS SUBSTANCE STORED 8 C.A.S.R 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D _ A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH D(TERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER r ❑ I STBEUIRDN ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLADW/RBERGLASS REINFORCED MASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVIWLCHLORDE 7Jti MINUM ❑0110%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE F� 10 GALVANIZED STEEL ER'%UNKNOWN F199 OTHER r ❑ I RUBBER UNED ❑2 MM LINING ❑ 3 EPDXY LINING n<�PILENOLIC LINING C.LININGINTERIOR ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN LINING ❑ GLINING MATERIAL COMPARBIE WITH IW§6 METHANOL? E]YES El NO ❑99 OTHER D.CORROSION ❑ I POLYETHUNE WRAP ❑2TAR OR ASPHALT ❑ NYIWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER r 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 jt) 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER r A U I 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 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 810 p%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 5 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 I 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 91 NONE P S UNKNOWN P S 99 OTHER r VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES NO V. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY N FACILITY ID R TANK ID k ® �U C� Oc� CURRENT LOCAL AGENC FACILIT'10 y APPROVED BY NAME PHONE F WITH AREA CODE PERYIT NUMBER PERMITAPPROVALDATE PERMIT EXPIRATION DATE /3 CHECK wPERMIT AMOUNT .SURCHARGE ANT. FEE CODE ^ECEIPTN BY, LW1 �, THIS FORM MUST BE ACCOMPANIED SY A FACILITY/SITE APPLICATION, FORM`A',UNLESS A CURRENT FORMA' HAS BEEN FILED