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STATE OF CALIFORIft WATER RESOURCES CONTOARD FORM V: UND GROUND STORAGE TANK PR RAM w' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLL ORMATION FOR EACH TANK. G MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT GE OF INFORMATION 7 PERMANENTLY CLOSED K 1 C3 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED $ FACILITY/SITE NAME WHERE TANK IS INSTALLED: FAIRGROUNDS INDUSTRIAL :PARK FARM TANK-YES❑ NO ❑ F-+ I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD A. OWNERS TANK ID# UNKNOWN B. MANUFACTURED BY: UNKNOWN N C. YEAR INSTALLED UNKNOWN D. TANK CAPACITY IN GALLONS: 10,OO II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [__j1 MOTOR VEHICLE FUEL D 2 PETROLEUV95 B. C. 1 UNLEADED LEADED ❑ 3 DIESEL F73 CHEMICAL PRODUCT D 4 OIL © 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ®80 EMPTYUNKNOWN ❑ 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.A C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ®95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER tiy ❑ 1 STEELIIRON F-] 2 STAINLESS STEEL ❑3 FIBERGLASS �4 STEEL CLAD WIFIBERGUISS REINFORCED PL" 0 B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑8100%METHANOLOOMPATIBLE FAP �N l MATERIALa ❑9 BRONZE ❑ 10 GALVANIZED STEEL ® 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING ••m'3D C.INTERIOR ❑5 GLASS LINING ❑ 6 UNLINED �'95 UNKNOWN Im= OD LINING Fnto 9 ISLINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION RAP 2TARORASPHALT 3VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC ma ❑ 1 POLYEDILENEW ❑ PROTECTION 5 CATHODIC PROTECTION ❑91 NONE [j]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 A9NKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A 965 UUNKNOWN A U 99 OTHER A U 1 STEEL/IRON 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 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A ©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 S 1 VISUAL CHECK P S 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 S 7 PRESSURETESTING P S 91 NONE 8 95 UNKNOWN P S 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED DUANTITY OF 3.WAS TANK FILLED WITH UNKNOWN SUBSTANCE SUBSTANCE REMAINING IN O GALLONS INERT MATERIAL? []YES '-o NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRI TE08 SIGNATURE) DATE SYDNEY LEVIN 10/13/89 LOCAL AGEN Y USk ONLY COUNTY N JURISDICTION 8 AGENCY P FACILITY ID M TANK ID a �] I I ;L I 4EE [10: 0 3 CURRENT LOCAL AGENCY FACILITY ID k LOATEPERMIT PHONE M WITH AREA CODE `/9126 PERMIT NUMBER PERMIT APPROEXPIRATION DATE CHECKh PERMIT AMOUNT SURCHARGE AMT. CEIPTN FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FA1 /SITE APPLICATION, FORM 'A',UNLESS A CURRENT TORM A' HAS BEEN FILED DATA PROCESSING COPY -