SITE INFORMATION AND CORRESPONDENCE

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I ' STATE OF CALIFOPP'klA WATER RESOURCES CO KOL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM mo TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑1 NEW PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION E3/PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE y �8 TANK REMOVED oq FACILITY/SITE NAME WHERE TANK IS INSTALLED:�� S pA. /afi"( � L S FARM TANK—YES❑ NO " 1. TANK DESCRIPTION COMPLETE ALL ITEMS—IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# BA. ANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: p 11. TANK CONTENTS IF(A.1),IS(MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A. E]K1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1�UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL /PROD CT ,�)4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WAST ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) I D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SiNGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER A?rl STEEUIRON ❑ 2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASSREINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER F—] 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LININGW95 ENOLIC LINING C. LINING�OR F-] 5 GLASS LINING ❑ 6 UNLINED NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT 3 V LW ❑4 PBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER I. IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERG OUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A; !95 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 Cp 95 UNKNOWN A U 99 OTHER F A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3I POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A CONCRETE A U 7I STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL ',`/tl'1 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SE ONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 5 7 PRESSURETESTING P S 91 NONE I P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PI TACE 1 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS I INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A! TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY N FACILITY ID# TANK ID# UM I I El EL 1 --1 ff 1c) / 1,2- Eo b i::�) LOCAL AGENCY FACILITY-(D APPROVED BY NAME PHONE N WITH AREA CODE 5'Y57-25760 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT Expimmd DATE CHECK R PERMIT AMOUNTURCHARGE AMT. Fi E CODE EIPT N BY: y FORME(6-29-6e) TIIIS FORM MUST BE ACCOMPANIE`l. -Y A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CUr'IRENT FORM`A' HAS BEEN FILED —FILE COPY