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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TINFORMATION AKPROGRAM ANK. ¢rG„ TANK PERMIT APPLICATIO A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH T TANK COMPLETE 1WPERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7,PERMANENTLY CLOS 4 MARK ONLY ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED W ONE ITEM INTERIM PERMIT d� A c FA�.�1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: ' 2, �, - L N✓ RM TANK-YES E] NO ❑ W y3-2�o3 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY B. MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS' C.YEAR INSTALLED v II. TANK C LATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE E ITEM D.LEADED ❑ 3 DIESEL e. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 3 CHEMICAL PRODUCT ❑4 OIL 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ Z WASTE ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#' HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D DOUBLEwALLEO F13 SINGLEWALLEO WITH IXTERIOR LINER ❑95 UNKNOWN A TYPE OF SYSTEM Z INGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFISERGIASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑810096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING PHENOLICLINING C.INTERIOR ❑6 UNLINED 95 UNKNOWN LINING [:] 5 GLASS LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 7yI99 OTHER NYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION ❑91 NONE LL.,��Q 95 UNKNOWN ❑ IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 91 NONE U 95 UNKNOWN A U 99 OTHER A A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A lk 6 CONCRETE A U T STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL y 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 41. S 1 VISUAL CHECKP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR p 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S T PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES E] NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK ID a PCHECK# TY N JURISDICTION# AGE O O OCAL AGENCY FACILITY ID N APPROVED BY N�1E PHONE N WITH AREA CODE BER C PERMIT APPRO A�L�DATi;�� PERMIT EXPIRATION DATE 2�'I / FEE CODE RECEIPT BY: PERMIT AMOUNT SURCHARGE ANY. FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYDATE TAPPROCESSINGOCOP`A,UNLESS ..JRRENT FORMA' HAS BEEN FILED