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STATE OF CALIFORIG WATER RESOURCES CONTF*BOARD 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 CLOSED TANK % ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE EE'B TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: r5 FARM TANK - YES ❑ NO ANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN —SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS - -- - - --- -- - -- 1� �A.l ). IS MA111�C[!, 4VIN 1-Irc 1 C 11 cOl b. Ir tiN.l), w nv � mnnncv, ..vmr cc. c .. cm v. A. ❑ 1 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 HAZARDOUS ❑ 80 EMPTY ❑ 5 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & G.A.S. # C.A.S. #: 111. TANK CONSTRUCTION MARK ONE ITEM OILY IN BOX A. B, C, a D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WAL ED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY NTAINMENT ❑ 99 OTHER PHONE N WITH AREA CODE 1 STEEU IRON ❑ 2 STAINLESS STEE ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLOR E ❑ 7 ALUMINUM ❑ 6 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ® 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING F__]5 GLASS LINING L]6 UNUNEO ❑ 95 UNKNOWN 1:1 IS LINING MATERIAL COMPATIBLE NTH 100% METHANOL? YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 9 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UN RGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 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 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U\7TEEL LYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U CLADW/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U THER _ V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECOND RY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S\9EUNKNOWN LECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 5 P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MOIYR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # s SUBSTANCE REMAINING IN INERT MATERIAL? © YES [:]NO GALLONS PHONE N WITH AREA CODE THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE ANC} CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE I f%d'AI AnFBI('V I ICF t1Nl V COUNTY # JURISDICTION # I AGENCY # ET 11a1 FACILITY ID # s TANK ID # aaa CURRENT LOCAL AGENCY FACILITY ID k r 70 APPROVED Y/ NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE MIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM W, UNLESS A CURRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY I C� cii r'J cl OO CD