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STATE OF CALIFORNIO WATER RESOURCESCONTROARD FORM V: UNDERGROUND STORAGE TANK PRO RAM n' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOW!1N9 INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT CHANGE OF INFORMATION ❑ ERMANENTLY CLOSE ANK ONE ITEM ❑2 INTERIM PERMIT F-14 AMENDED PERMIT ❑�69TEMPORARY TANK CLOSURE 8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Cf 1 A. OWNERS TANK IDH , B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL H t PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO 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.H C.A.S.H: A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEA ❑ 95 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 E]6 POLYVINYLCHLORIDE F-17 ALUMINUM E]B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBEALINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC UNING C. INTERIOR5 GLASS LINING IJNUNED ❑ 95 UNKNOWN LINING ❑ © F-1 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 ❑YES 0 N ❑99 OTHER I D.CORROSION ❑ i POLYETHLENE WRAP ❑ 2TAR OR ASPHALT ❑ 3'AWL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE La95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 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 U A�ll 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A8 CONCRETE A U ?STEEL CLAD WERE A U 8100%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. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P t 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Na P S 6 PRECISION TESTING P S 7 PRESSURE TESTING ®91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED TE LAST USED(MO/YR) 2. ESTIMATED UANTITYOF 3.WAS TA "K�FF L'LED WITH SUB`,1TAI4 REMAINING IN INERY A IAL? ❑YES ❑ NO vV Vim\ GALLONS w THIS FO HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY H JURISDICTION H AGENCY H FACILITY ID H TANK ID H b 1 b D � p 1 CURRENT LOCAL AGENCY FACILITY ID H APPROVED BY NAME PHONE H WITH AREA CODE MAP PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EX RATION DATE CHECK N PERMIT AMOUNT URCHARGE AMT. FEE CODE RECEIPT p BY: �^ FORM B(6-29-B6) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A,UNLESS A CURRENT FORMA' HAS BEEN FILED �\ DATA PROCESSING COPY