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J I A I C UP CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDEF.WeiOUND STORAGE TANK PROIL AM TANK TANK PERMIT APPLICATION INFORMATION b COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. L MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE W 8 TANK REMOVED 07 c-n FACILITY/SITE NAME WHERE TANK IS INSTALLED: $r.'J'CJ -,e- ,U ,, C, FARM TANK-YES❑ NO Eg N ra I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 CA A OWNERS TANK IDE 8. MANUFACTURED BY: a) O YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 20'a&7 If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM .D A. 1 MOTOR VEHICLE KIEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL Tri PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED d C.A.S.E C.A.S.E: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,s D A TYPE OF ❑ DOUBLE WALLED ❑3 SINGLE WALLED NTH EKTEROR LINER ❑ 95 UNKNOWN SYSTEM 22 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RSERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑8 POLYVINYL CHLORIDE ❑ 1 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBEHUNED ❑2 ALKYDUNING F-13 EPOKYLINING ❑ 4 PHENOLIC LINING C LINING INTERIOR ❑ 5 GLASS UNING ❑6 UNLINED ❑ 95 UNKN6MN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEINANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYE7HLENEWRAP ❑2 TARORASPHALT ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC 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 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U i 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 1 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL CLAD W/FRP A U 8 100%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. S ' VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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 N 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 COUNTY E JURISDICTION E AGENCY E FACILITY ID E TANK ID E o k L CURRENT LOCAL AGENCY FACILITY ID E APPROVED BY NAME PHONE E WITH AREA CODE tf-O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE r 1 CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTS FORMS(8-29-88) THIS FORM MUST BE ACCOMPANN,,,.A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A,TIENT FORMA' HAS BEEN FILED - - DATA PROCESSING COPY --