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STATE OF CALIFORI, WATER RESOURCES CONTE ^-90ARD FORM V: UNIRGROUND STORAGE TANK PRGGRAM ' s 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 8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE E I / FACILITY/SITE NAME WHERE TANK IS INSTALLED: , V FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I A. OWNERS TANK Id# U K B. MANUFACTURED BY: C. YEAR INSTALLED D.,TANK CAPACITY IN GALLONS: ` k. ' 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.T),IS NOT MARKED,COMPLETE ITEM D. i A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL1 PRQDUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑G AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPT ❑Y 95 UNKNOWN 2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM Q,BELOW) 1 D MOTOR HAZARDOUS BSTANCE STOR D&C.A.S.#OFC.A .S.#: � �I/F-� SOC_1J�CT' E .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,a D i A TYPE OF ❑ f DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 9S UNKNOWN SYSTEMNGLEWALLBI ❑4 SECONDARY CONTAINMENT ❑99 OTHER r La'ISTEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC MATERIAL AL B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIOE- ❑7 ALUMINUM E:] 8 100%METHANOLOOMPATIBLEFaP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER 1 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPO)CY UNING ❑4 PHENOLIC LINING ' C. INTERIOR LINING ❑5 GLA �6 UNLINED ❑95 UNKNOWN f ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑,NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLI NE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 RBERGLASS REIWRCED PLASTIC PROTECTION5 CATHODIC PROTECTION 1 NONE ❑ ❑95 UNKNOWN ❑99 OTHER ' IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE j A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3.GRAVITY A U 91 NONE A drIbS UNKNOWN A U 99 OTHER B.CONSTRUCTION AN 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 jUNED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A &P 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 A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10a%METHANOL COMPATIBLE FRP j A U 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. P 5 1 VISUAL CHECK p S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS E P S 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER I� VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE - I 1. ESTIMATED DATE LAST USED(MOIYR) .2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH J SUBSTANCE REMAINING IN- INERT MATERIAL? E:]YES E] NO �+ - GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. . i APPLICANTS NAME(PRINTED&SIGNATURE) DATE 1 LOCAL AGENCY USE ONLY 1 COUNTY* JURISDICTION# AGENCY# FACILITY ID# TANK!D# I A CURRENT LOCAL AGENCY FACILITY fD# APPROVED Y NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE. �f Q CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE'CODE RECEIPT# BY: - I' t FORM B(6 29 68) THIS FORM MUST BE ACCOMPA ir: BY A FACILITYISFTE ' ' APPLICATION, FORM A,UNLE itURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY `