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STATE OF CALIFORPM WATER RESOURCES CONT BOARD FORM V: UN RGROUND STORAGE TANK PR GRAM TANK `j TANK PERMIT APPLICATION INFORMATIONa L COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH T K - MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 MANEN Y TA ONE ITEM E:]2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TAN OVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7z J,1,2 7/f4-e-7FAR*TAlW-,YES[ff NO ❑ L-4 C •O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—80 SPECIFY A. OWNERS TANK IDX B. MANUFACTURED BY: C. YEAR INSTALLED 9 D. TANK CAPACITY IN GAL NS: a-zr'j2 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLE'FEITEM D. CA A. I MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ 1 UNLEADED (ff3—DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.X C.A.S.X: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A B,C,&D A.TYPE OF ❑ IB&BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER F-195 UNKNOWN SYSTEM LEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 SUEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCREFE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 100%MEMMOLCOMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYO LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNUNED95,DNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [—] NO I1—LL''--,�I(I//990THER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑3 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE %UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTENTYPE A 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 LINED TRENCH A U 91 NONE A XJ5 UNKNOWN A U 99 OTHER A U / STEEL/IRON ASTAINLES 2 S STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM U 8 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER Vs LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. J/ 8 1 VISUAL CHECK P S INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 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 GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? E]YES E] 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 8 SIGNATURE) DATE ( LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION 4 AGENCY N FACILITY ID 8 TANK ID 8 E= G od aoo / CURRENT LOCAL AGENCY FACILITY 117 Y APPROVED By NAME PHONE 4 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE a � CHECK$ PERMIT AMOUNT SURCHARGE AMT. FEE CODE di RECEIPT 9 BY: I ORM H(s-29 e3) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY