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STATE OF CALIFORNIA WATER RESOURCESCONTRO&OARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY LOSE T� 1O ONE ITEM ❑2 INTERIMPERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /T FARM TANK-YES❑ NO N FACILITY/SIT NAME WHERE TANK IS INSTALLED: / O I. TANKDES RIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (� cz A. OWNERS T NK IDR 'Z B. MANUFACTURED 8V: C.YEARINST LLED Q D. TANK CAPACITY IN GALLONS: 00 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. U�f1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HA RDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN 92 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MO OR VEHICLE FUEL,ENTER NAME OF C.A.S.W HAZARDO S SUBSTANCE STORED 8 C A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 NGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 MEL CIAO W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2ALKYD LINING ❑3 EPDXY LININGd�HENOUC LINING C INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSIO ❑ 1 POLYETHLENEWRAP 2TAR OR ASPHALT ❑ 3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTI N ❑5 CATHODIC PROTECTION 7191 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING I FORMATH IF APPLICABLE A. SYSTEM TYPE A U - SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER TI N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BO B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 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 CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEE A U 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 S I VISUAL CHECKP INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 40 8 8 PRECISION TESTING P 9 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 2. ESTIMATED QUANTITY OF 3.WA TMATERI L'WITH 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN INERT MATERIAL? DYES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED &SIGNATURE) DATE LOCAL AGENCY USE ONLY COJ U�NTYR�� JURISDICTION R AGENCY R FACILITY ID R TANK ID# APPROVED BY NAME � � PHONEp WITH AREA CODE^. CURRENT LOCAL AGENCY FACILITY ID# PERMIT NUMBER 70 PERMIT APPROVAL DATE PERMI EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODEECEIPT# BY: FORMB(6-29- ) THIS FORM MUST BE ACCOMPANIED BY A FACILITY%ATAPPPR TION, OR MP ',UNLESS A CURRENT FORMA' HASBEENFILED