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STATE OF CALIFORNI ' WATER RESOURCES CONTRC OARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 'SCHANGE OF INFORMATION ❑7 PERMANENTLY �j 1 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED (/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: r7 71, W �� FMM TANK-YES❑ NO N I. TANKDESCRIPTION COMPLETE ALL ITEMN S-IF UNKNOWN-SO SPECIFY � �[ A. OWNERS TANK ID# A"f B. MANUFACTURED BY: OD C. YEAR INSTALLED LI/rk�yq%1,�,/ D. TANK CAPACITY IN GALLONS: 1J0� 11. 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 PETROLEUMC. [-] 1 UNLEADED 2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 L B. PRODUCT ❑4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS MPTY [:]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 CONSTRUCTION MARKONE ITEM ONLYIN BOXA,B,C,BD A. TYPE OF ❑ 1 UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER ,❑5 1 STEEURON ❑2 STAINLESS STEEL F-13 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASRC B.TANK CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBSERUNED [:]2 ALMUNING ❑ 3 EPDXY LINING F-14 PHENOLIC LINING LINING ❑ 5 GLASS UNING F-16 UNLINED ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METH4NOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETH ENEWRAP ❑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 IFAPPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE U UNKNOWN A U 99 OTHER S.CONSTRUCTION SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE Cl MATERIAL U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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 S 3 VADOSE WELLS 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 5 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME RINTEDBStGNATURE) /1 r DATE OIL Lwd LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE lri LLi 3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOU NTSURCHARGE AMT. FEE CODE PECEIPT# BY: /7 FORM E f6?q53) THIS FORM MUST BE ACCOMPANI "Y A FACILITY/SITE APPLICATION, FORM 'N,UNLESS KINIRRENT FORMW HAS BEEN FRED /✓/_ DATA PROCESSING COPY