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STATE OF CALIFORNIA- WATER RESOURCES CONTROI ')ARD FORM V: UNDEh'dROUND STORAGE TANK PRO(*9AM GO TANK TANK PERMIT APPLICATION INF RMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 ORMATION FOR EACH TANK. MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑7 PERMANENTLY ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT F]6 TEMPORARY TANK CLOSURE E]8 TANK REMOVEDC y FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0s L n ANK-YES Q!NOg] LI •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID N B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D DDD 11. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A7),ISNOT MARKED,COMPLETE ITEM D. CJT A. E1 MOTOR VEHICLE FUEL ❑2 PETROLEUM R. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL �j ppppUOT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.N CAS.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ I DOUBLEWAUED ❑3 SINGLE WALLED WITH LXTEROR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER (YI 'SfEEUIRON ❑2 STAIME86STEEL E]3 RBEBD ASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONatETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALXYDUNING ❑3 EPDXYLINING ❑4 PHENOWUNING LINING ❑5 GLASS UMNG ❑6 WAIN® ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH/00A METHANOL? ❑YES ❑NO ❑99 OTHER f/ IL CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIN CAMIFID FORCEDPIASTIC L 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER IL CONSTRUCTION A 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 1 STEELARON A U 2 STAINLESSSTEEL 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 10D%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 8 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS ®8 4 ELECTRONIC MONITOR P 8 5 GROUND WAT ER MONITORING WELLS P 8 6 PRECISION TESTING P 6 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) Z.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE 4 LOCAL AGENCY USE ONLY COUNTY* JURISDICTION N AGENCY N FACILITY ID No 3(e TANK IDN OOA ml23 o y -r CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE WAY CHECK# PERMIT AMOUNT I $URCHARGE AMT. FEE CODE 'CEIPT# BY; 4 FOHMB(6-29-M) THIS FORM MUST BE ACCOMPANIED BYAFACIUTY/SITEAPPUCATIOK FORM •A•,UNLESSACURRENT FORMA' HASBEENFILED f1 DATA PROCESSING COPY