SITE INFORMATION AND CORRESPONDENCE

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STATE OF CALEFORNI Al WATER RESOURCES CONTR' BOARD ••': : FORM V: UND�GROUND STORAGE TANK PR GRAM TANK PERMIT APPLICATION INFORMATIONo TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWINGINFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYrr 0 NK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLE?L-�!/1 -5 , 54,r/ 70-AQ( liV FARM T K-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ION' B. MANUFACTURED BY: 00 C, YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ('pO 11. TANKCONTENTS IF(A-1).IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. .1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM VI C. E] 1 UNLEADED ❑2 LEADED 3 DIESEL i 3 CHEMICAL PRODUCT ❑ 4 OIL RODUCT ❑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&C.A.S.N C.A.S.M 111. 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 EV2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELBRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 1 W%METHANOL COMPATIBLE FAP MATERIAL 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING PHENOLIC LINING LINING ❑5 GIASSLINING F-16 UNLINED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO S99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 NYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91.NONE LK95 UNKNOWN ❑ 99 OTHER IV. PIPING'INFORMAAON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 UNKNOWN A U 99 OTHER B.CONMUCT 13N A 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 I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERGL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ` �6E L CHECK�11G �214VENTONCIUATlON P $�VADOE WELLS P $ 4 ELECTRONIC MONITOR P $ 5 GROUND WATER MONITORING WELLSISION TESING P S P $ 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 4.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES :❑NO GALLON$ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY , COUNTY IF JURISDICTION N AGENCY P FACILITY ID it TANK TD100E DT FF Ll E L-0 OD Z y s L91 CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE 0 WITH AREA PERMIT NUMBER PERMIT APPROVAL DATE �PERMITWIRATIO�IDATE CHECKY PERMIT AMOUNT RIIRCNARGE AMT. FEE CO2 BT: FORM B(s-2988) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FIRED DATA-PROCESSING CQPY�