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STATE OF CALIFORNIS WATER RESOURCES CONTR&OARD FORM V: UND RGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION ' TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - �a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑' ANK REMOVED �� N FACILITY/SITE NAME WHERE TANK IS INSTALLED: L4�j L . 1-06- 1 L FARM TANK-YES❑ NO A I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# It I B. MANUFACTURED BY: ik- �- C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS'. II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL 3 CHEMICALPRODUCT 4 OIL - ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY 5 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CA S,M: HAZARDOUS SUBSTANCE STORED 8,C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 5 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS [:] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK [�] 5 CONCRETE 6 POLYVINYLCHLORIDE F-1 7 ALUMINUM El B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE F-] 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER M 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C LINING INTERIOR [:] 5 GLASS LINING F-16 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH IN%METHANOL? ❑YES ❑ NOOTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Ea25 P6WN ❑ 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 LU 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 U UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS0%METHANOL A U 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADW/FRP A U 8 10046 METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL U 5 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. P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P 3 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) EMAINING IN ALLONS INERT MATERIAL? YES ❑ NO — SUBSTANCE R G THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# C) G G I CURRENT LOCAL AGENCY FACILITY ID N APPROVED B�ME ' f -�� PHONE#WITH AREA CODE R �tS C l/, PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKk PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: ' FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY