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STATE OF CALIFORN& WATER RESOURCESCONTROARD :,'•u^ FORM V: UNDERGROUND STORAGE TANK PR AM m TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1,W6RMATION FOR EACH TANK. v- MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 P ANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED M fD P_ FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: 02/,jS `C T (� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 0 B. MANUFACTURED BY: C)&Je'l'l CO/r-7 C. YEAR INSTALLED yfj D. TANK CAPACITY IN GALLONS: 100c) 11. TANK C TENTS 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. TM a;7q L❑ 3 CHEMICAL PRODUCT ❑ 4 OIL i PRODUCT ION GAS5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ,BELOWI D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF u / C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF UBLE WALLED ❑3 SINGLE WALLED WITH El(IERIOR LINER ❑ 95 UNKNOWN SYSTEM EZ2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT X N OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100°6 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 P OUC LINING C. INTERIOR5 GLASS LINING F-16 UNLINED 95 UNKNOWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT Q,3>AYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE M95 UNKNOWN [:] 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH 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 B.CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 91 NONE A U UNKNOWN A U 99 OTHER FIBERGLASS A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 PODIVINYLCHLORI (PVC) A U 4 100%METHAN L A U 91 NONE C.MATERIAL A U 5 ALUMINUM A�CONCRETE A U 7 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MON�ORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 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,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY ! COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 y CURREN LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE X7N 5 r PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE CEIPT# BY: �� FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIEWA FACILITY/SITE APPLICATION, FORM IN,UNLESS ATMIRENT FORMA' HAS BEEN FILED 'ADATA PROCESSING COPY