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STATE OF CALIFORI& WATER RESOURCES,CONT06 BOARD "••TI FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ' ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEWPERMIT ❑3 RENEWALPERMIT 191ircHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED W FACILITY/SITE NAME WHER94ANK IS INSTALLED: �i. -> FARM TANK•YES❑ NO Ln I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-SO SPECIFY W A. OWNERS TANK 10 N #_ .3 B. MANUFACTURED BYm C.YEAR INSTALLED 1 D. TANK CAPACITY IN GALLONS: c CZQ 11. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED C M LETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. EL rJHNLEADED ❑ LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL B. PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 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 6 C.A.S.N C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I BLE WALLED ❑3 SINGLE WAILED WITH EXTERIOR UNER E]95 UNKNOWN SYSTEM . AUED ❑4 SECONOAR(CONTAINMENT ❑99 OTHER ` I STEELIMON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B IDA MEIRANOL COMPATIBLE FRP 1 MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ I KOM UNED ❑2 ALXYOUINNG 3 EPDXY LINING ❑4 PHENOLIC LINING C.LINING ❑5 GLASSLNNNG F-16 UNLINED UNKNOWN IS LINING MATERAL COMPATIBLE WITH IDOA METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYERILENEWRAP ❑2 TAR OR ASPHALT ❑ 3 V LWRAP E:] 4 FIBERGLASS REINFORCED PLASTIC .I PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 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 GRAVITY A U 91 NONE A U 95 UNKNOW A U 99 OTHER B.CONSTRUCTION A U INGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U1 STEEL/I 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 U S CONCRETE A U 7 STEEL CLAD WIFE? A U B 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. 1 VISUAL CHECK P - 2f INVENTORY HECONCILIAM1ON P S 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �y 1 • B 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 I.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? YES NO 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 Y JURISDICTION N AGENCY N FACILITY 10 N TANK ID N CURRENT LOCAL AGENCY FACILITY ID N ' APPROVED BY NAME PHONE N WITH AREA CODE /L-i7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE NI CHECK 1 PERIMT AMOUNT SURCHARGE FEE CODE RECEIPT 4 BY: ��9-t3'92 jai FORM B(5-29-M) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FILED OATAR 1