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;. +'�•a�rY�nrrt _from STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `a MARK ONLY UE] 1 N PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: g'D �� FARM TANK-YES❑ NO I. TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IO A. OWNERS TANK ID# Q d0 B. MANUFACTURED BY: C. YEAR INSTALLEDkL, D. TANK CAPACITY IN GALLONS' /000 IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C PLETE ITEM D. 0D A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑/OIL1 ppODUCT ❑4 GASAHOL ❑5 JET FUEL ❑8 AVIATION GAS ❑5 HAZARDOUS ; fm EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑W OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FU ,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# �. C.A.S.#: .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH W ERIOR LINER ❑95 UNKNOWN SYSTEM re4sNGLEWAALLEO ❑4 SECONDARY CONTAINMENT ❑99 OTHER I IA1. ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR -RUBBER UNFD ❑2 DUMNG ❑3 ETOXYLINING ❑4PHENOUC UNING LINING ❑ 5 GLASS LINING LLjlf UNUNED ❑95 UNKNOWN l ❑ IS UMNG MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I PO�Q`N" NE WRAP TM ORASPHALT F-13 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATYFgDIC PROTECTION ❑91 ND14E ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AU SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN 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 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP 1 A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER 1 /V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. M-[.� P S 1 VISUAL CHECK (OS 2 INVENTORY RECONCILIATION P 8 3 VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS •7� ,f )6 PRECISION TESTING P B 7 PRESSURE TESTING P S 91 NONE P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE _ 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFGALLONS 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID R 3 d D / / 0 (o1010101 / 1 CURRENT LOCAL AGENCY FAµITY APPROV PHONE#WITH AREA CODE O C PERMIT NUMBER PERMIT AP7PS DATd PERMIT EXPIRATION DATE i g4 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM a 0-7A8) THIS FORM MUST BE ACCOMPA BY A FACILITY/SITE APPUCATIOK FORM 'A',UN URRENT FORMA HAS BEEN FILED SII' DATA PROCESSING COPY