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TATE OFKALIFO RN IA`Y y . WATER RESOURCES CONTROLARD FORMV:: UNDERGROUND STORAGE TANK PROGRAM N _ wo TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING ItIFORMATION FOR EACH TANK. 0 MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑2 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED W ARM TANK-YES NO ❑ IVB FACILITY/SITE NAME WHERE TANK IS INSTALLED: Yo v I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED L D. TANK CAPACITY IN GALLONS: O` Il. TANK CONTENTS IF(A.1),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 El3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT Pi❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN ❑ 2 WASTE iE1 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# G.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT . ❑I99 OTHER ❑ 1 STEELPRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑,4 STEEL CLAD M FIBERGLASS REINFORCED PLASTIC S.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 NUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL F-19 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING El EPDXY LINING 4 P LIC LINING C. INTERIOR 5 GLASSUNING 6 UNUNED- 95 UNKNOWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT n 9/(L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE E�T%UNKNOWN ❑ 99 OTHER V. 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 5 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 5 UNKNOWN A U 99 OTHER ► A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM AV CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YRI 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,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE OCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# El 1 1. © a 1 iVI 1F(Iolol ;l IURRENT LOC AGENCY F IL # APPROVED BY NAME, PHONE#WITH AREA CODE FnMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE r RECEIPT# BY: r B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS SEEN FILED DATA PROCESSING COPY,