SITE INFORMATION AND CORRESPONDENCE

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fi.,r'fi y.� a�."� �a .. ..4!'�k•'y.T .o f; .. _. .. .-. _-, -:"• �, Rey r :.r4 n.�!-�1Y^..re.� A'J, "i'1i, STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 14 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT [a"5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE Ll ONE ITEM 2 INTERIM PERMIT 1:14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE [-]B TANK REMO FACILITY/SITE NAME WHERE TANK IS INSTALLED: f --' � , ,1 itu. }°&,Vk� � �.. FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-)SO SPECIF, A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED ) D. TANK CAPACITY IN GALLONS: II. 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. G. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCjT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN �( 2 WASTE I ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF j HAZARDOUS SUBSTANCE STORED&C.A.S.# u-j-Je f C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D A.TYPE OF [::]-1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER I ® 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ! ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-] 5 CONCRETE E-]6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ! F-] 8 10095 METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [o 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING E]5 GLASS LINING ❑ 6 UNLINED �( 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10095 METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ! ❑ 4 FIBERGLASS REINFORCED PLASTIC 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 G�AVITY A U 91 NONE A U 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 Aa 95 UNKNOWN A U 99 OTHER 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 C. MATERIAL A U 5 ALUMINUM A U 6 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 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADQSF WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS r P S fi PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLAPE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF j 3. WAS TANK FILLED WITH SUBSTANCE REMAIN3NG IN i GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND�iiO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) I DATE ! LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# J1 :6:El- CURPRENTLOCAL AGENCY FACILITY ID# -APPITOV 0Y N E) `�rPHONE#WITH AREA CODE L iv„ V�.t PEPERMIT APPROVAL DATE PERMIT EXPIRATION DATE ! CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE EIPT# BY: f 1 FOAM B(6-29-88) THIS FORM MUST BE ACCOMPANIEL;JY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM`K HAS BEEN FILED y.t FILE COPY; , __ .