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. ..a .. .._-.. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ±•`' �^ � <br /> I <br /> FORMV:: UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION '' <br /> TANK '' <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TAMC. <br /> MARK ONLY W PERMIT 3 RENEWAL PERMIT Ej 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT p 6 TEMPORARY TANK CLOSURE S TANK REMOVED <br /> FACILITY/SITE NAME WHERE K IS INSTALLED: U CJ hl V�%` FARM TANK-YES <br /> ❑ NO .� <br /> co <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY U? <br /> A. OWNERS TANK ID# -zr- <br /> B. MANUFACTURED BY: <br /> C. YEAR INSTALLED 82 <br /> D. TANK CAPACITY IN GALLONS: OCA <br /> II. TANK C ENTS 1F(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED E - DFD 3 DIESEL <br /> 0 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS 60 EMPTY ❑95 UNKNOWN 2 WASTE k 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / J ✓1 <br /> HAZARDOUS SUBSTANCE STORED$C.A.S.# / C.A.S- <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8If <br /> A.TYPE OF ❑1 LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM SINGLE WALLED A SECONDARY CONTA4NMENT ❑99 OTHER I <br /> 1 STEEL/IRON E] 2 STAINLESS STEEL 03 FIBERGLASS F A STEEL CLAD WIFIBERGLASSREINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM6 100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED ❑2 ALKYD UNING 3 EPDXY UNINGt R�95 <br /> PH C LINING <br /> C.INTERIOR 5 GLASS LINING ❑6 UNLINED UNKNOWN <br /> LINING - <br /> IS LINING MATERIAL COMPATIBLE WITH 1Oft METHANOL? YES E]NO 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT 3 V RAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION Ej 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A SUCTION A U 2 RRESSURE A U 3 GRAVITY A U 91 NONE ' A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE {� 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4'FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A �U'')B,CONCRETE A U 7 STEEL CLAD WIFRP A U .8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 6>R5 UNKNOWN A U 99:OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> / P S 1 VISUALCHECK 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS %P 8 4 ELECTRONIC MONITOR P- S 5 GROUNDWATER MONITORING WELLS <br /> v <br /> PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE iP 8 95 UNKNOWN P 8 99 OTHER <br /> I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED IMO! R)- ' 2. ESTIMATED OUANTITY OF 'I ., 1 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN � INERT MATERIAL? YES [�]NO <br /> GALLONS ., <br /> J <br /> THIS FORM HAS <br /> BEEN'COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,is TT. <br /> TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> I <br /> i <br /> LOCAL AGENCY USE ONLY I <br /> COUNTY M JURISDICTION N AGENCY# FACILITY ID N TANK ID# <br /> LoU C� C� v <br /> [CHECK <br /> ENT LOCAL AGENCY FACILITY ID i APPROVED BY NAM PHONE N WITH AREA CODE <br /> i <br /> IT NUMBER <br /> PERMIT APPROVAL DATE PE MIT XPIRATION TE <br /> it <br /> 0 PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE cGEIPT d eY: <br /> 11V- ti_... ._ �•,•r���• +RF.n1�PLpRUIE►,My A Gdru tTY7s1TE,APPLICATION. FORM_W,UNLESS AuuARENT: FORMA' HAS BEEN FILED w� r <br />