SITE INFORMATION AND CORRESPONDENCE_CASE 1

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STATE OF CALIFORNIA WATEFLRESOURCES CONTROL BOARD °: 0, FORM V: UNDERGROUND STORAGE TANK PROGRAM _�TANK PERMIT APPLICATION INFORMATION TANK � COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. N, z f1a r MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E]7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3,47,2 J5. � FARM TANK-YES❑ NO .v�. 1 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID A 1 B. MANUFACTURED BY: { C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: i 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C [::] 1 UNLEADED ❑2 LEADED ❑3 DIESEL I ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET 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 FU&PNTfR NAME OF HAZARDOUS SUBSTANCE STRED&C.A.S.# i C.A.S.If: 1 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ! ❑ 1 STEELARON ❑2 STAINLESS STEEL - ❑3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONC%* ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE I�I'Y ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER i C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING E]4 PHENOUC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN , ❑IS LINING MATERIAL COMPATIBLE WITH I OD%METHANOL? ❑YES ❑NO ,T999 OTHER V z--_--' D.CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC i 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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CON TRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER F A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10096 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. P II 1 VISUAL CHECK P II 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P II 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P II 6 PRECISION TESTING P II 7 PRESSURE TESTING P 91 NONE P 8 95 UNKNOWN 5P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF3.WAS TANK FILLED WITH 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 8 SIGNATURE) DATE 1 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 101010 11 CURRENT LOCAL AGENCY FACILITY 10 Y APPROVED BY NAVE VV PHONE M WITH AREA CODE d PERMIT NUMB R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 1 PERHIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM a(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM W HAS BEEN FILED DATA PROCESSING COPY