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STATE OF CALIFORNih WATER RESOURCES CONTR OARD FORM V: UNDERGROUND STORAGE TANK PR RAM ` TANK TANK PERMIT APPLICATION INFORMATION COMP ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - _ z o / 10 MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEDa ' GJ FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 FARM TANK-YES[::]'NO FV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C.TI O A. OWNERS TANK ID# B. MANUFACTURED BY: CO C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: H. TANK CONTENTS IF(A-1) S MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM6. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑ 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&C.A.S.# C.A.S.# III. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF 1 OOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT Z ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL EK3 FIBERGLASS ❑4 STEEL CLADW/RBERGIASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ i RUBBER LINED ❑2 KYDUNING ❑ 3 EPDXY LINING ❑4 PHENOUC LINING LINING ❑ 5 GLASS LINING ff 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑9907 R D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAA OR ASPHALT ❑3 VINYL WRAP4 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 AM SUCTIONA U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTIIUCTION A U i SINGLE WALLED A DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) <U-> FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 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 PLACE 1. MAT D DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑VES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# DE] 16 1 o / = 10 o o CURRENT LOCAL AGENCY FACILITY ID# APPROV D Y AME II PHONE#WITH AREA CODE �F 40 TIS/ PERMIT©BPE PPRO AL OAT PERMIT E%PI TION DA E \p CHECK# PERMIT AMOUNT SURCHAR EAMT FEECODE 2 3 R CEIPT# BY: \V`y` FORM B(6-29-88) THIS FORM MUST BEACCOMPANIED YAFACILITY/SREAPPLICATION, FORM 'A!,UNLESS PENT FORMA' HASBEENFILED DATA PROCESSING COPY