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STATE OF CALIFORN: 'WATER RESOURCES CONTROBOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION �� 4 I COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH CH TANK. MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PEflMIi CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T ) ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED a► FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES QNO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY co A. OWNERS TANK ID# ' 8. MANUFACTURED BY: N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: AO O IL TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A E54MOTOR VEHICLE FUEL ❑2 PETROLEUM B C. ❑1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JEF FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 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.# C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑1 0 LE WALLED E]3 SINGLE WALLED WITH EXTERIOR UNEP ❑95 UNKNOWN SYSTEM LgKSINF WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER EEL/IRON ❑25'TAINLESS STEEL ❑3FIBERGLASS ❑4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK 5 MATERIAL CONCRETE ❑6 POLYVINYLCHLORIDE 8106%METHANOL COMPATIBLE FRP ❑7 ALUMINUM ❑ ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER I C. INTERIOR ❑1 RUBBER UNED 2 ALKYD MING 3 EPDXY LINING 4 PHENOLIC UNING ❑ ❑ LINING E] ❑5 GLASSUNING LINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO oollroo�ER [,rdd63�U D.CORROSION ❑1 POLYETHLENE WRAP ❑2;TWORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION 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 FIBERGLASSPIPE A U 9/ NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9-GALVANIZED STEEL A(F)VI 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 8 1 VISUAL CHECK 2 INVENT(RY RECONCILIATION P B 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P A$ 8 PRECISION TESTING P S 7 PRESSURE TESTING P 8 9/ NONE P 8 95 UNKNOWN P 8 99 OTHER ` �VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN 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. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I o� CURREN OCAL AGENCY FACILITY ID# APPROVE BY NAM PHONE#WITH AREA CODE �J PERMIT NUMBER PERMIT APPROVAL DATE I PEPIMIT EXPIRATION DATE CNECKk PEgM1T AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY