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STATE OF CALIFORNI• WATER RESOURCES CONTROOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK 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 ONE ITEM 2 INTEflIM PERMIT ❑ 7 PERMANENTLY CLOS ANN ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: -700 e. 6FARM TANK•YES NO ❑ L4 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �0 A. OWNERS TANK ID p B. MANUFACTURED BY: C. YEAR INSTALLED le- D. TANK CAPACITY IN GALLONS: (COQ W II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.%IS NOT MARKED,COMPLETE ITEM O A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL i PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 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&C.A.S.N C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A o EOFED WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNFA 95 UNKNOWN NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER TEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC ONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ONZE ❑ t0 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR BBERUNED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC UNING LINING ❑5 GLASS UNING ❑6 UNUNED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 190%MEIRANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑I POLYEMLENE WRAP ❑2 TAR OR ASPHALT ❑3 VIWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION91 NONE ❑ ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDER GROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY=U95 A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRA U 95 UNKNOWN A U 99 OTHERA U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVIN4 FIBERGLASSPIPE A U 91 NONEC. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CA U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHERB 100%METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VAOOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 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 SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH OALLONB 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 6 SIGNATURE) DATE t LOCAL AGENCY USE ONLY COUNTY p JURISDICTION p AGENCY p r n FACILITY ID p TANK ID O CURRENT LOCAL AGENCY FACILITY ID p LS' O APPROVED BY NAME PHONE 4 WITH AREA CDDE PERMITNUMBER I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMITAMOUNT SURCHARGEAMT. FEE CODE 6-//�d \ °CEIPT 4 BY: � `v\ FORMS(6-2966) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FOgM'A' HAS BEEN FILED DATA PROCESSING COPY