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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD w: FORM V: UNDEhmorROUND STORAGE TANK PROI..wAM ' 1 TANK TANK PERMIT APPLICATION INFORMATION b COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED Q� FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 sdr ,C C',- FARM TANK-YES❑ NO m N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY cm A. OWNERS TANK ID 4 B. MANUFACTURED BY: C) C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q�I II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL IL�:7_II(_2 PETROLEUM B. C. ❑ 1 UNLEADED [:] 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT [0 4 OIL 1-11 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY ❑ 95 UNKNOWN [02 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.8 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A TYPE OF I DOUBLE WAS ❑3 SINGLE WALLED WITH SMF40R UNER ❑%UNKNOWN SYSTEM R 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ %OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/RSERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOUC UNING LINING ❑5 GLASS UNING ❑ 6 UNLINED ❑ 95 UNKOINN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I POLYVHLE14E WRAP ❑2 TAA OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICA13LE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 0 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE - C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U S 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. I ' P E I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 96 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONS) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH GALLONS 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. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION 8 AGENCY N FACILITY ID B TANK ID F �� r d Ill CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 0 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT R BY: FORM B(sag-66I THIS FORM MUST BE ACCOMPANIL"A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A.LENT FORM WAW HAS BEEN FILED DATA PROCESSING COPY /�