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STATE,10PCALIFOR10 WATER RESOURCES CONTOL BOARD a .c FORM V -UNDERGROUND STORAGE TANK PROGRAM ani TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE SEPARATE FORM WITH THE FOLLOWING 1 FORMATION FOR EACH TANK. c MARK ONLY ED' I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY I C ( ONE ITEM <,❑2 INTERIM PERMIT - ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE Ci FACILITY/SITE NAME WHERE TANK IS INSTALLED: fqI -TARM TANK-YES 7 NO ❑ I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 5 33G C Lc A. OWNERS TANK ID I B. MANUFACTURED BY: (L C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),19 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. LiI UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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 8.CAS.0 CA.S.R: III: TANK CONSTRUCTION MARKONE ITEM ONLYIN BOXA,B,C,&D A.TYPE OF ' ❑ I.DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER ❑ I STEELIIRON ❑ 2 STAINLESS STEEL 3 FIB ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK r75 CONCRETE 6 POLYVINYL CHLORDE 1 M INUM MATERIAL, ❑ ❑ ❑8100%MEIHANOI COMPATIBLE FRP 1'. ❑ 9 BRONZE _ 16 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER G INTERIOR - ❑ I RUBBER LINED ❑2 ALXY,D UNING ❑ 3 EPDXY LINING ❑7VHENOUC LINING LINING. F75 GLASS LINING ❑ 6 UNLINED ffIyUNKNOWN ❑ IS UNING MATEAW.COIAPATIBLE WITH 100%METHANOL? ❑YES NO 990THER D. CORROSION ❑ 1.POLYETHLENE WRAP ❑ 2 TARORASPRALT ❑ NYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 cATHODICPROTEcTK* ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE IFABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I 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 STEELIIRON A U STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U / 04FIGLASS PIPE A U 91 NONE C. MATERIAL .'.' A U 5ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 5 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 VISUALCHECK . P O 2 INVENTORY RECONCIUATION P 8 3 VADOSE WELLS P�11 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE 8 5 UNKNOWN P 8 99 OTHER Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑yES ❑ NO -THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,)S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION# AGENCY 8 FACILITY ID 8 TANK ID 8 ren (� CURRENT LOCAL AGENCY FACILITY 101 APPROVED BY NAME PHONE I WITH AREA CODE z 4 PERMITNUMBER - PERMIT APPROVAL DATE PERMIT EXPIRATION DATE O CHECK# PERMITAMOUNT SURC —DE AMT. FEE CODE ECEIPTI 8y;