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STATE OF CALIFOROA WATER RESOURCES CON...OL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK .TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED i FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7�% S�, ,/ FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK[ON c� B. MANUFACTURED BY: L_ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: U If. TANK CO TENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑2 PETROLEUMETI"'P'FIODUCT C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PROOUCT ❑ 4 OIL ❑ 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 FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.M C.A.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D A.TYPE OF ❑ WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER El 95 UNKNOWN SYSTEM 2 WALED ❑ 1 SECONDARY CONTAINMENT ❑ 99 OTHER NK 1 STEEUFON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑ 1 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATTE B.TAERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ I ALUMINUM E] e 100%MEMMOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNM ❑2 LINING ❑ 3 EPDXY LINING ❑ /PHENOLIC LINING C.INTERIOR LINING ❑ 5 GUSSUMNG 8 UNLINED ❑ 95 UNKNOWN ❑ LS LINING MATERIAL COMPATIBLE WITH 100%METHM 100 ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHIENEWRAP ❑2 JAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NOW ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROU1�1D, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A & 1 SI A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/I A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 8 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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P t s GROUND WATER MONITORING WELLS P 8 PRECISION TESTINO P S 7 PRESSURE TESTING P S 91 NONE P 6 95 UNKNOWN P 9 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION 0 AGENCY f FACILITY ID/ TANK ID A E o CURRENT LOCAL AGENCY FACIL["IDI APPROVED BY NAME ( PHONE I WITH AREA CODE � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT I BY: n / Innu A u.9G.AA% THIR FnRM UlIRT RF IrrnuoAmicn a I c.ro mv,oirc&r"ir.vin u rn 0 u -w