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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM Qp TANK > - TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF ATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑D RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO K ONE ITEM ❑2 INTERIMFERMTT ❑ 1 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED OBJ FACILITY/BITE NAME WHERE TANK IS INSTALLED: p` (��, r 7 0 �� C�(S yy� FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A OWNERS TANK IDI (� B. MANUFACTURED BY: U(� C.YEAR INSTALLED Gt(C D. TANK CAPACITY IN GALLONS: 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 PETROLEUM ©�I`U C. NLEADED ❑2 LEADED ❑ D DIESEL ❑0 CHEMICALPRODUCT ❑1 O0. B. I PRODUCT ❑/ GASAHOL ❑ 5 JET FUEL ❑S AVIATION GAS ❑ 5 HAZARDOUS ❑M 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 A C.A.S.I C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.S.C,i D A TYPE OF ❑WALED ❑7 SINGLE WALLED WITH WERIOR UFR ❑%IIItma SYSTEM 2 B WALLED ❑1 SECOND M CONTANYENT ❑ %OTHER I STEELIRON ❑2 STAINLSSSTEEL ❑7 FIBERGLASS ❑/MR CLAD W/FIBERGLASS REP60RCFD PLASTIC B.TANK ❑ MATERIAL5 comalm ❑6 PaYWNYLOtORDE ❑ I ALNIINW ❑I IOOIALIEIIMNOLCDMPATIBLEFRP ❑ ❑9 BRONZE ❑ 10 GAlYAM2FD STEEL ❑ %l1KKIg1W! 99 OTHER ❑I MMUNEO ❑�LNING ❑T EPDXY LINING ❑ 7 74NCWLMNG G INTERIOR UNING ❑5 GlAssum IG 6 LELBIED ❑%UI MWN ❑IS UNNG MATRAL COIRATIBLE WITH IW%METHANOL? ❑YES ❑NO ❑99 OTHER [�PROTECTION ON ❑ I PoIYEfftENEWMP ❑2 ORASPIIALT ❑ 7 YWR WRAP ❑ /FIBERGLISS REINFORCED PLASTIC ❑ S CATIIOOIC PROTECTION 91 NONE ❑%UNOIOWN ❑ W OTHER IV. PIPING INFORMATION CIRCLE A IFA13OVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A Y A U 2 PRESSURE A U 2 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A USINGLE W A U 2 OOUBL.E WALLED A U J LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U - EELAR6 A U 2 STAINLESSSIEEL A U S POLYVINYL CHLORIDE Inc) A U A FIBEROUSSPIPE A U 91 NONE C.MATERIAL A U A U a CONCRETE A U 7 STEEL CLAD W/FRP A U 6 10 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 t ( VISUAL CHECK P • 21NVENTORYRECONGLIATION P t WENS P • IELECTflONIC MONITOR P • SOflOUND WATER MONITORING WELLS P t. •PRECISION TESTING P t 7 PRESSURE TESTING P � ) P t 91 NONE 95 UNKNOWN P • 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YRI 2. ESTIMATED QUANTITY OF 1 WAS TANK FILLED WITH p/�w �` SUBSTANCE REMAINING IN 1 19 INERT MATERIAL? ❑YES v` GALLON? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION t AGENCY I FACILITY ID E TANK IO C7C-1 CURRENT LOCAL AGENCY FACILITY ID t APPROVED BY NAME PHONE F WITH AREA CODE gof� S cc / 7 1 PENMITNUM•ER PEgY1T APPROVAL DATE PERMIT EXPIRATION DATE 1 1\\�� CHECK PEAMITAMOUNT URCHARGE AMT. FEECOOE :CEIPT/ •Y; ✓✓✓////