SITE INFORMATION AND CORRESPONDENCE

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r ' YSTATE OF CALIFoRr� .l WATER RESOURCES CONTn BOARD .•-�°, ,. FORM V: UNDERGROUND STORAGE TANK PROGRAM - TANK PERMIT APPLICATf N INFORMATION TANK .. � CQIMPLETE A SEPARATE FORM WITH THE FOLLOWING INFATION fOR EACH TANK. _ 1 MARK ONLY'. : ❑ 1 NEW PERMIT . ❑3 RENEWAL PERMIT RANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ONE ITEM _ ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT E 1 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITYISITE NAME WHERE TANK IS INSTALLED: �� C FARM TANK-YES NO ❑ (` 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECI `/j�37� L C A. OWNERS TANK ID p B. MANUFACTURED BY: C. YEAR INSTALLED D. T NK CAPACITY IN GALLONS: �Q II. TAIK 92NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. I A 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL f 3 CHEMICAL PRODUCT 4 OIL t PRODU T 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&CA.S.0 C.A.S.t III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER STEELIIRON 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/R8ERGLASSREAFORCEDPLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ I ALUMINUM ❑8 1009.)METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL [].95 UNKNOWN 99 OTHER C INTERIOR -❑ 1 RUBBFAUNED 2 ALKYD LINING 3 EPDXY 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? DYES D 110 ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGR UND,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 i A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 OLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL - A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL CLAD W/FRP A U 6 100%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 SEC. NDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P $ 1 VISLIALCHECK P 6 2 INVENTOR`/RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS � P $ 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P B 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 SUBGALLONS STANCE REMAINING IN INERT MATERIAL? ❑YES [DNO I 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 COUNTY It JURISDICTION N AGENCY B FACILITY ID/ TANK ID 1I L I Oat.g d c)l CURRENT LOCAL NCY FACILITY ID f APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE O� CHECK A PERMIT AMOUNT SURCHARGE AVT. FE CODE ECEIPT By; j G�/ r FORM_6(6-29-68) THIS FORA MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, Fq R M `A',UNLESS A CURRENT FORMA' HAS BEEN FILED