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STATE OF CALIFOR WATER RESOURCES CONOARD a FORM V: UND GROUND STORAGE TANK PR RAM wo TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMM FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 / ,'j -S /-1 X41,1 %/e -7AA6 4 CA" FARM TANK- YES I\ 1 NO -SFT I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY' 7 1- �, tw A. OWNERS TANK ID # B. MANUFACTURED BY: Via - C. YEAR INSTALLED D. TANK CAPACITY IN GALLON 9 II. TANK CONTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D. A. FrVMOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-]3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: III. TANK CONSTRU,OTION MARK ONE ITEM ONLY IN BOX A, B, C, A D Ill A. TYPE OF 1DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM E-10NGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 3 GRAVITY A U 91 NONE ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL El?3' FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-]7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP A U ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE El1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING E]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED A U 9 GALVANIZED STEEL A IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑NO LY5NKNOWN THER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VI RAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN E]99 OTHER viviro a inrvnmm 1 Ivry GIHULt A Ir A Vt GHUUNU, U IF UNDERGROUND, BOTH IF APPLICABLE F 3. WAS TANK FILLED WITH A. SYSTEM TYPE A U 1 SUCTION AV 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 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER CURRENT LOCAL AGENCY FACILW ID # z t - ^ A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A19 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 8 100% 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 SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 2� P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF F 3. WAS TANK FILLED WITH FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES [:]NO = GALLONS 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 LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # = I I I I E[ LL I j I q] I L-31 Lo 1 010 1 CURRENT LOCAL AGENCY FACILW ID # z t - ^ APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER CHECK # PERMIT AMOUNT FORM B (6-29-88) THIS FORM MUST BE ACI PERMIT APPROVAL DATE SURCHARGE AMT PERMIT EXPIRATION DATE FEE CODE BY A FACILITY/SITE APPLICATION, FORM `A', UNLESS DATA PROCESSING COPY # -I SY: FORM `A' HAS BEEN FILED d