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• STATE OF-CALIFORNl WATER RESOURCES CONTROARD FORMV: UNDERGROUND STORAG TANK PROGRAM ,mom o TANKTANK PERMIT APPLICATI N INFORMATION L�CO�APLETIE A SEPARATE FORM WITH THE FOLLO ING INFPRMATION FOR EACH TANK. Io I NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSE AAAAK ONLY. ❑ ❑� CO ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED W FACILITYISITE NAME WHERE TANK IS INSTALLED: t/�� 1�1 L�LQyj FARM TANK-YES NO ❑ IV 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I-) _s7V (j] A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED D. TA K CAPACITY IN GALLONS: 11. TAIJK CON TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS 140T MARKED,COMPLETE ITEM D. A. LZ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMVI C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL [J.3 CHEMICAL PRODUCT ❑ 4 OIL ODU ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8,C.A.S.N C.A.S.q: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF . ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELPRON 2 STAINLESS STEEL F13 FIBERGLASS [DAD 4 STEEL CI WIFIBERGLASS REINFORCED PLASTIC B TANK ❑ MATERIAE 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRP ., ;. 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER C.INTERIOR ❑ I RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOUCUNING UNING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1W%METHANOL? YES ❑ ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑96 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 CRAviTY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 L NEI)TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESS STEEL A U 3 P LYVINYL CHLORIDE(PMC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEL CLAD W/FRP A U 9 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECOI JDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK ' P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S B PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLA E 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH aAuans SUBSTANCE REMAINING IN INERT MATERIAL? E:]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BLAST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) GATE LOCAL AGENCY USE ONLY COUNTY 11 JURISDICTION 0 AGENCY 8 FACILITY IDN TANK ID 41 13[ql © � CURRENT LOCAL NCY FACILITY ID tt APPROVED Y NAME PHONE U WITH AREA CODE . 0 Mho z PEA>111T NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK it PEl .RMIT AMOUNT 0SURCHARGE AMT. FEE ODE ECEIAT■ BY: `. FORM 8(6-29.88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FO R M 'A',UNLESS A CURRENT FORM W HAS BEEN FILED