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WATER RESOURCES CONT*BOARD gl fit` a h STANCE OF CALIFORI' v��:_ FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK G TANK PERMIT APPLICATION INFORMATION u r COMPLETE A SEPARATE FORM WITH THE FOLLOWINFORMATION FOR EACH TANK. 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T MARK ONLY ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT / 7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: � ` FARM TANK -YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY B. MANUFACTURED BY: A. OWNERS TANK ID # �7 _�` D. TANK CAPACITY IN GALLONS'. �7 Lr� C. YEAR INSTALLED / II. 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 ❑ 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 C.A.S. #: HAZARDOUS SUBSTANCE STORED & C.A.S. II III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF F-]1 DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER El 95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W /FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 IN% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑YES 0 NO 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP 2 TAR OR ASPHALT ❑ 3 VIN'YLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 bNKNOWN ❑ 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 LINEDTRENCH A U 91 NONE k 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLFSSSTEEL A U 3 POLYVINYL CHLORIDE (PVQ A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL .�AA..: U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP CA,� 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSEWELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS R P S 99 OTHER S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH E7�:= SUBSTANCE REMAINING IN INERT MATERIAL? YES �NO :-� GALLONS '"`'��"YYYY THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLIC'" T'S NAM�•IPRINTED SIGNAT1aRE)–) DATE i LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # r I -L] CURRENT LOCAL AGENCY FACILITY ID # ^ PERMIT AGENCY # FACILITY ID # lolOT APPROVED BY NAME - I I a ul — PERMIT APPROVAL DATE I I PERMII EXPIRATION DATE CHECK #PERMIT AMOUNT SURCHARGE AMT. I FEE CODE I RECEIPT # TANK ID # Ia PHONE # WITH AREA CODE BY: FORM B (6-29-8B) THIS FORM MUST BE ACCOMPANIEVP A FACILITY, FORM COP A', UNLESS ATWRENT FORM `A° HAS BEEN FILED DATA PROCESSING