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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P ANENTLY CLOSEDTANKS TANK REMOVED i+lri ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 0,5 FARM TANK-YES❑ NO -7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1' B. MANUFACTURED BY: A. OWNERS TANKID# �5��/ �) D. TANK CAPACITY IN GALLONS: V C.YEAR INSTALLED II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. UNLEADED ❑ 2 LEADED ❑3 DIESEL A EgfMOTOR VEHICLE FUEL ❑ 2 PETROLEUM F-13 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAB ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /J C.A.S.#: HAZARDOUS SUBSTANCE STORED&r,AS # All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,A D i LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN E 99 OTHER 2 BINGLEWALLFD ❑4 SECONDAM COMAINMENT ❑STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6190%METHANOL OOMPATIBLEFRP ❑9 BAONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 A DURING ❑3 EPDXY LINING ❑ 4 PHENOUCUNING C.INTERIOR ❑5 GLASSUNING 6 UNLINED ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER D. CORROSION ❑ 1 POLYETHILENEWRAP 2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INIFORMATI IN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 190%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 05 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. p 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P SS 99GOPOUENRO WATER MONITORING WELLS $ PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE' P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED( /y I 2. ESTIMATED QUANTITY G I INERT MATERIAL? ❑YES ❑ NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, T. IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# Fo FACILITY ID# TANK ID# APPROVED BY ME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY PERMIT NUMBER PERMIT APPIR VALDATE PE IT EEXPIPIRATI DATE CHECKX PERMIT AMOUNT SURCHARGEA FEE CODE RECEIPTX 9Yo FORM B(3-7-8B) THIS FORM MUST BE ACCOMPANIED dY A FACILITY DIA A PROCESS NORM 'A',UNLESS A L RENT FORMA' HAS BEEN FILED