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STATE OF CALIFORNIA " WATER RESOURCES CONTROL BOARD FORMV:: UNDERGROUND STORAGE TANK PROGRAM _ u- TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ' .a%n' z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑S CHANGE OF INFORMATION ❑7 P MANENTLY CLOm (� ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I ��✓ FARM TANK-YES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK Ip p /I qj ' B. MANUFACTURED BY: C. YEAR INSTALLED ) D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED. ❑3 DIESEL ❑3 CHEMICAL PRODUCT L A OIL i� ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET-FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN �2 WASTE ❑7 METHANOL 9 OTHER(DESCRIBE IN ITEM D,BELOW) ' D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF _ 1 HAZARDOUS SUBSTANCE STORED&C.A.S.4 C.A.S.R: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,6,&D A.TYPE OF ❑ I UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 4 1 B.TANK STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 MEL CLADW/FIBERGLASS REINFORCED PLASTIC � MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE- ❑ 7 ALUMINUM ❑B 10096 METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZEDrSTEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBERLINED ❑ 2 ALKYDUNING ❑3 EPDXYLININO ❑4 PHENOLICUNING LINING ❑ 5 GLASS LINING Q 6 UNLINEDW95 UNKNOWN E] IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 NYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE E1795 UNKNOWN ❑99 OTHER ' IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDER ROUND,BOTH IF APPLICABLE J. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION 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 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 5 ALUMINUM A A6 CONCRETE. A U 7 STEEL CLAD W/FRP 'A U 8 100%METHANOL COMPATIBLE FRP ` A U 9 GALVANIZED STEEL A W 95 UNKNOWN A U 99 OTHER F V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED.- P S 1 VISUAL CHECK P g 2 INVENTORY RECONCILIATION P S YADOSE WELLS P�45EULECTRONICMONITOR�P5 GROUNQ WATER MONITORING WELLSS 6 PRECISION TESTING P SlpESURE TESTINGNONE PNKNOWN 9 OTHER t VI. INFORMATION ON TANK PERMANENTLY,CLOSED IN PLACE ((( 1. E TIMATED DATE LAST USED(MO/YR) 2. ES7ZANCE TED QUANTITY OF 3.WAS ANK FILLED WITH A REMAINING IN INE /<yATERIAL? ❑YES ❑NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNO EDGE,IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY A JURISDICTION 0 ADENCY N FACILITY ID E TANK ID E 4 d l D D CURRENT LOCAL AGENCY F40LITY ID N .' APPROY D BY NAIVE PHONE t WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXPIRATION DATE 1 CHECK N PERMIT AMOUNT RCHARGE ANT. FEE CODE RECEIPT R BY: i FORMB(6-29-88)(6.29-88) THIS FORM(MUST BE ACCOMPANIED� UNLESS A NT fORIA'A' HAS BEEN FILED �, •- 1�'ACiLITY1SREAPPLICATiON, FORM 'A', DATA P'4ACFCPl�1r-�-nov