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STATE OF CALIFORNIfa WATER RESOURCES CONTRO1OARD FORM V: UNDE GROUND STORAGE TANK PRO" AM TANK TANK PERMIT APPLICATION INFORMATION COMPL TE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 211*'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 ❑8 TANK REMOVED CS FACILITY/SITE NAME WHERE TANK IS INSTALLED: C �'� = FARM TANK-VES❑ NO ..� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# I B. MANUFACTURED BY: C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. p A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMG ❑ 1 UNLEADED LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL B. 1 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 x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I SLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINEA ❑95 UNKNOWN SYSTEM r0-U,`($ING ALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 9 STEEUIRON ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE El6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM E] 810D%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 DLINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 ETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE ❑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 rti PRESSURE A U 3 GRAVITY A U 99..OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCHA 5 UNKNOWN 99 OH A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 6 7 PRESSURETESTING P S 91 NONE- P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(t40 Y 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH (/lt// SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS 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 IIDf# lo CURRENT LOCAL A /Y FACILI� APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER 22 PERMIT APP OVAL GATE PERMIT E%PIRATION ATE 1 CHECKX PERMIT AMOUNT SURCHARGEAMT. FEE CODE I IRECEIPT# BY: FORMB(3-7-B8) THIS FORM MUST BE ACCOMPM11MA FACIUTY/STTE APPLICATION, FORM `X,UNLESS RENT FORM'A' HASBEENFILED DATA PROCESSING COPY