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�t STATE OF CALIFORNIf WATER RESOURCES CONTRCgr OARD FORMV:. U NDLROUND STORAGE TANK PROAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATIONT P MANENTLY CLOSED TANK II ONE:ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSU E TANK REMOVED ig �)/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES ED NO;;, Z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I® A. OWNERS TANK ID# 14 B. MANUFACTURED BY: Vic- C. Jc-C.YEAR INSTALLED O. TANK CAPACITY IN GALLONS: --56-6 IL TANK CONTENTS IF(A.1),13 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO LETE ITEM D. I"'a A. E3'1'MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED [:] 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT F-] 4 OIL PRODUCT E]4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY 0 95 UNKNOWN 2 WASTE El 7 METHANOL ❑ 99 OTHER(.DESCRIBE W ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.W t XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D I, A TYPE OF ❑ 1 DOUBLE WALLED [:]3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEMSINGLEWALLED E]4 SECONOARYCONTAINMENT 99 OTHER DRi 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS A STEEL CLAD WlFIBERGUISSREINFORCED PLAS7IC R'Tug 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 10096 METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER 1 RUBBER UNED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING C LOR 5 GLASS LINING [gA—W AED 95 UNKNOWN LINING � IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES Ej NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP [:]2 TAR OR ASPHALT F-] 3 VINYL WRAP 4 FIBERGLASS RUNFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION NONE Ej 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION 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 99 OTHER L CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER I A 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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 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. l i P 8 i VISUAL CHECKP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS B 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER i I Vl. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? �YES [:] NO Ir THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, IAPPLICANTS NAME(PRINTED&SIGNATURE) DATE j LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# mi FT I I I o Fo-To-113 loolct, �J- V] CURRENT LOCAL AGENCY FACILITY ID K APPR BY NAME/ PHONE III WITH AREA CODE /�! L PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E IRATION DATE CH ECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY-- I, FORM s(3a-66) THIS FORM MUST BE ACCOYPANIE A FACILITYISII'E APPLICATION, FORM`A',UNLESS A ENT FpRY`A' HAS BEEN FILED E DATA PROCESSING COPY