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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSFD Tpnur ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE V8TANK REMOVED �/ I FACILITY/SITE NAME WHERE TANK IS INSTALLED: ',W ; ,6 e kOd FARM TANK-YES NO �❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IO A. OWNERSTANKID# 8. MANUFACTURED BY: C. YEAR INSTALLED D TANK CAPACITY IN GALLONS: W 11. 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 ❑4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL E]6 AVIATION GAS ii ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESC IBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �p HAZARDOUS SUBSTANCE STORED&C.A.S.# A CAS.#: N All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D I A TYPE OF ❑ 1 L1IX1&E WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 COFKAETE 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 10)%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-] I RIBBER LINED ❑2 AMD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS UMNG V 6 UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL CDMPATIBLE WITH 100%MERMNOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 OR ASPHALT ❑3 VINYL WRAP F-]4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AU 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FAP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER 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 8 2 INVENTORY RECONCILIATION 8 VADOSE WELLS P1 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS / P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P 1 NONE- P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST SED(MO/YR) 2. ESTIMATED 0 ANTITY OF 3.WAS TANK F LED WITH SUBS A E AINING IN INERT M L? YES NO GALLONS THIS FORM HAS bEEN COMPLETED UNDER PENALTY OF FlkkjURY,AND TO THE BEST OF WY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 2-Ittz 3 CURRENT LOCAL AGENCY FACILRY ID# APP O ED A E PHONE#WITH AREA CODE mfbC� /� `L3 t PERMIT NUMBER PERMITAPPROVAL DA I PERMIT EXPIRATION DATE 1 CHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE �RECEIPTN BY: FORMS(3-7-88) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM `A7NLESS AMIZENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY