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STATE OF CALIFORNM& WATER RESOURCES CONTROOARD FORM V: UNDE ROUND STORAGE TANK PROGRAM TANK � TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING'INFORMATION FOR EACH TANK. Z 10 ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 ff.RMANENTLY CL MARK ONLY ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED' X L /I/I( M TANK-YES NO ❑ I� 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CC A. OWNERS TANK ID N :z- B. MANUFACTURED BVljjr. C.YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑/OIL ❑ 1 PRODUCT ❑1 GASAHOL [-] 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS C]60 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&CAS.N C.A.S.B: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ 1 DDIBLEWALISI ❑3 SINGLE WALLED WITH WERIOR LYER ❑951EN(NOWN SYSTEM ❑2 SINGLEWAUBi ❑1 SEWNDARYCDNTNNMENT ❑99 OTHER ❑ 1 SIEEUWON ❑2 STNMESS STEEL ❑3 RBERGLASS-- ❑1 STEEL CUD W/RBERGUSS REINFORCED RASTIC B.TANK 5 CONCRETE • El ❑6 PMYVIM'LOLOADE ❑7 AUAWAM ❑B IOD%METHANOL COMPATIBLE RP MATERIAL.: ❑9 WMZE ❑ 10 GALVANIZED STS ❑95 UE(NOW1T ❑99 OTHER ❑ G INTERIOR I RIBBER( o ❑2 ALOD LINING ❑3 FPWUNNG E]1 PHBIOLIC LUNG LINING - ❑5 GlASSINBNG ❑61MJN® ❑95 IYL(NOW11 ❑SUNNGMATBMLCOWATMLEWTIH1004METHAMIL7 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLM"UM WRAP ❑2 TM ORASI MUT ❑3 VINYL WRAP ❑ FIBERGLASSREIMORCEDRASTIC PROTECTION ❑5 CATHODIC P90TEM ❑91 NONE ❑95 UE010NN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND,U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FAP A U B 10D%MMIANOLCOMPATIBU 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 B 1 VISUAL CHECK P B 2 INVENTORY RECONCILIATION P 9 3 VADDSE WELLS P B A ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P B 6 PRECISION TESTING P B 7 PRESSURE TESTING P B 91 NONE P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) - 2. ESTIMATED ODANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING W GALLOW WERTMATERLLL7-.. [:]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(PRINTED B SIGNATURE) �. DATE _ LOCAL AGENCY USE ONLY COUNTY P JURISDICTION B AGENCY B FACILITY ID f TANK IO B CURRENT LOCAL AGENCY VAGAM ID F APPROVED BY NAME PHONE E WITH AREA CODE 17-1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT is CHARGE AMT. FEE COOS 141 IPT N ABY: THIS FORM MUST RE ACCOMPANIED BY A FACILITY/SITE APPLICATION. FORM 'A'.UNLESS A CURRENT FORMA' HAS BEEN FILED!D