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STATE OF CALIFORNIS WATER RESOURCES CONTR9OARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION N COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATIONTAN ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑21NTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑STANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I CZE FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY [AZ:OffNE,R87I�j�'K IDB. MANUFACTURED BY:C. YTALLED r D. TANK CAPACITY IN GALLONS: iLZ J f� 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),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 ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY UNKNOWN ❑2 WASTE ❑7 METHANOL E]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.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D [A., YPE OF ❑1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWNYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER❑ 1 STEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTICANK 5 CONCRETEATERIu ❑ ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 IM%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZEDSTEEL U NKNOWN ❑99 OTHER C.INTERIOR ❑1 RUBBER UNED ❑2 ALKYO LINING ❑3 EPDXYLINING ❑q PH OLICUNING LINING ❑5 GLASS LINING ❑6 UNUNED UNKNOWN '- ❑ISLINING MATERIAL COMPATIBLE WITH IDA METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYSHLENE WRAP ❑2 TAR ORASPHALT ❑3 VINY WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 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 A U 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN 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 UU 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZED STEEL A N AS UNKNOWN A U B 100%METHANOL COMPATIBLE FRP ��..../// 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 g 2 INVENTORY RECONCILIATION P $ E WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S fi PRECISION TESTING P 3 PRESSURETESTING 8 91 N P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL?- ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE/S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID q �❑ O C7'� � 3 � O TDKIDq O CURRENT LOCAL AGCY FACILITY ID p APPROVED BY NAME PHONE p WITH AREA CODE EN 1 1 jlq PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E%PIRATION DATE NECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORMB(fi-29-88) THIS FORM MUST BEACCOMPANIE ., AFACILITY/SITE APPLICATION, FORM 'A',UNLESS =RENT FORMA' HASBEENFILED DATA PROCESSING COPY