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STATE OF CALIFORNI WATER RESOURCES CONTRL..30ARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION TANK. OMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH III ❑ 1 F-1NEW PERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY MARK ONLY oA„ ONE ITEM ❑2 INTERIM PERMIT ❑ ; ENDED PERMIT ❑� 6 TEMPORARY TANK CLOSURE [:]B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: N s-7jkll &ZZTANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1 A. OWNERS TANK IDM 6 1 B. MANUFACTURED BY: N C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: c II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM . �+ A. gi MOTORVEHICLEFUEL ❑ 2 PETROLEUMC. ❑ 1 UNLE2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT E] B.4 OIL PRODUCT ❑4 AIDEDGASAHOL ❑ 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.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPEOF ❑ DOABLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM M2 SINGLEWALLED ❑4 SECONDARVOONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 10096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER [:] 1 RUBBER UNEO ❑ LKYO UNING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNI NO C. INTERIOR LINING ❑5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP FIXTAR 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 IF APPLICABLE A. SYSTEM TYPE1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER UC B. CONSTRTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95.UNKNOWN A U 99 OTHER U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A�ll 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%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. NkfP 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 8 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTI MATED DATE LAST USED 2, ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 6 SUBSTANCE REMAINING IN J�OALION$ INERT MATERIAL' E]YES NO THIS FOR AS BEEN COMPLETED U DER PENALTY OF PE J AND TO THE EST O Y KNOWLEDGE, IS TRUE AND CORRECT. Uj P ICANT'S(/N�AWM_,E,�PRINT BI N URE) IL/// DATE GIS, '(I�wFF//T/ 1• LOCAL AGENCY USE ONLY :&F&k COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# m = = I 1 12101310 ° -06 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: ! ,� FORMB(3-7-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A7,UNLESS A URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY