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STATE OF CALIFORO WATER RESOURCES CONT BOARD " FORM V: UNDERGROUND STORAGE TANK PROGRAM �,��,�� TANK' ' TANK PERMIT APPLICATION INFORMATION -�za COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z Ci MARK ONLY '- ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑I AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O FACILITYISITE NAME WHERE TANK IS INSTALLED: Of FARM TANK-YES© NO ❑ N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY O CO A OWNERS TANK ID 8 ✓; B. MANUFACTURED BY: C.YEAR INSTALLED ,1,/: D. TANK CAPACITY IN GALLONS: r G p II. TANK ONTENTS 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 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 1 OIL LJ j PRODUCT ❑I 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&CAS.8 C.A.S.0: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,iD A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR VIER ❑ 95 UNKNOWN SYSTEM. ❑2 SINGLE WALLED A SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 1 STEEL CLAD W7FIBERGUSS REINFORCED PLASTIC B.TANK M s CONCRETE ❑fi POLYVUNL CHLORIDE ❑ 7 ALUMINUM ❑B ROD%METHANOL COMPATIBLE FRP AERWL. ❑I BRONZE ❑ ID GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RIBBERUNED ❑2 ALKYD LINING ❑3 EPDXYLWING ❑/PHENOLICUNING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ISUMNG MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYEIILFNEWRAP ❑2 TAR OR ASPHALT ❑ 3 VIWLWRAP ❑ 1 FIBERGUM REINFORCED PLASTIC PROTECTION : [:]5 GIIOOCPflO7ECTION [_ 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.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEIARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P B I ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 6 91 NONE -P-8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION P AGENCY P FACILITY ID I TANK ID Y CURRENT LOCAL AGENCY FACILITY ID B APPROVED BY NAME PHONE I WITH AREA CODE PERMIT NUM BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERYR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: ,;�- FORM B(6-29.86) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED