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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMV: / STORAGE TANK PROGRAM ' TANK v TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ;: MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ,e K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /� FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 7 �' L-17�1 FARM TANK-YES❑ NO 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Ip A. OWNERS TANK IDN ©,� B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I. TANK C-09flENTS IF(At),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CQ LETE ITEM D. cnW A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMe. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ~ ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JE F FUEL ❑6 AVIATION GAS N ❑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 8 C.A.S.N C.A.S.N: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,a D A.TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER Eris UNKNOWN SYSTEM ❑2 SINGLE WALIID ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I SHEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVIWL CHLORIDE ❑7 ALU ❑8100%METHANOL COMPATIBLE FAP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNE3 ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4,PLIC UNING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VI ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE EJ15 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 2ESSU A U 3 GRAVITY A U 99 OTHER B. COMSTAUCTION A U 1 SINGLE WALLED A U DOUBLE WALLED A U 3 LINED TRENCH A U UNKNO A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUMA U 6 CONC A U 7 STEEL CLAD W/FRP A U B 1 BD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UUNKNO N A U 99 OTHER 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 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P i(95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [_ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY I COUNTY N JURISDICTION# AGENCY N FACILITY ID 8 TANK ID k © a / 6 1 t C, o I o CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE } CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT K BY- / FORM B(3-7-a6) THIS FORM MUST BE ACCOMPAN,,, 4 A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A URRENT FORMA HAS BEEN FILED DATA PROCESSING COPY