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STATE OF CALIFORNIO WATER RESOURCES CONTRCOOARD <br /> FORM V: <br /> UNDERGROUND <br /> STORAGE TANK PRO RAM <br /> TANK TANK PERMIT APPLICATION INFORMATION o <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> C161ia aH,R <br /> MARK ONLY Wl NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM 2 INTERIM PERMIT 07 PERMANENTLY CLOSED <br /> 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED / <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: / 2 J (: g_ O r <br /> I. TANK DESCRIPTION COMPLETE ALL iTEMS-IF UNKNOWN-SO SPECIFY FARM TANK-YES❑ NO <br /> A. OWNERS TANK ID# z` <br /> EnTAANLe <br /> FACTURE(] BY' - � <br /> C. YEAR INSTALLED <br /> CAPACITY IN GALLONS: <br /> N. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. MOTOR VEHICLE FUEL 2 PETROLEUMk <br /> $ C 1 UNLEADED [:j 2 LEADED <br /> 3 CHEMICAL PRODUCT 0 q OIL 3 DIESEL � <br /> 5 HAZARDOUS 0 80 EMPTY ED 95 UNKNOWN PRODUCT � �OL 99JOTHERET LDESCRI$ 6 AVIATION GAS <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF N ITEM D,BELOW) <br /> HAZARDOUS SUBSTANCE STORED&C.A.S. <br /> CAS.#: C <br /> Xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D <br /> A. TYPE OF DOUBLEWALLED 3 SINGLE WALLED WITH Ek7ERI0R LINER <br /> SYSTEM 2 SINGLEWALLEp 4 SECONDARY CONTAINMENT 95 UNKNOWN <br /> Q 99 OTHER <br /> B.TANK Ear STEELPRON 0 2 STAINLESSSTEFL ❑3 FIBERGLASS �4 STEEL CLAD WlFIBERGU4SSREINFORCED PLASTIC <br /> MATERIAL a 5 CONCRETE ❑6 POLYVINYL CHLORIDE 7 ALUMINUM 0 8 1013%METHANOL COMPATIBLE FRP <br /> Q 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING E] 3 EPDXY LINING �4 PHENOLIC UNI NG <br /> LINING �5 GLASS LINING a6 UNLINEQ <br /> 95 UNKNOWN <br /> El IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES E-] NO f 1 99 OTHER <br /> I).CORROSION E] 1 POLYETHLENE WRAP [:]2 TAROPASPHALT 3 VINYLWRAP l� <br /> PROTECTION 4 FIBERGLASS REINFORCED PLASTIC <br /> 5 CATHODIC PROTECTION E]91 NONE Ej 95 UNKNOWN E]99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE <br /> A U 7 STEEL CLAD W/FRP Af u J8 10045 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER +� <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br />�I ! P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> [jam P S 6 PRECISION TESTING p S 7 PRESSURE TESTING P S 91 NONE <br /> - S 95 UNKNOWN P $ 99 OTHER <br /> INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DAT T USED(MO/YR) <br /> 02. ESTIMATED OUANTI OF 3 WAS TANK ,ILLED WITH <br /> N SUBSTANCE REI�AI1 IN IAL? <br /> / r GALtaNs INERT �YES E] NO <br /> fY� THIS FORM HAS BEEN COMPLETED CINDER PENALTY OF PEA,! RY,AND TO THE BEST OF MY E <br /> KNOWLEDG , 1S TRUE AND COAAEGT <br /> APPLICANT'S NAME(PRINTED&SPGNATURE) <br /> DATE <br /> 00 <br />`( LOCAL AGENCY USE ONLY <br /> 11�yS COUNTY# JURISDICTION# AGENCY# <br /> +Vl FACILITY ID# TANK ID# <br /> / c> 0 0 <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> A <br /> l 7- PP <'j/YE BY AME PHONE#WITH AREA CODE <br /> � L� YrX <br /> PE MIT NUMBER PE TAP R Y L D TE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCH RGE AM . <br /> FEE CODE RECEIPT# <br /> BY: <br /> FORM B 13-7-66) THIS FORM MUST BE ACCOMPANI€D BY AFACILITY/SITE APPLICATION, FORM `A',UNLESS A vURENT FORM'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />