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STATE OF CALIFORNI)o WATER RESOURCES CONTROOPARD FORM V: UNDERGROUND STORAGE TANK PROGRAM s; p TANK TANK PERMIT APPLICATION INFORMATION u TANK COMP ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. G, IC MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL05E�TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FARMZES❑ NO ❑ IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: to I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWgSOSPECIFNY 0�C. WNERS TANK ID 11 ALLONS', (XXL EAR INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D B C. ❑ 1 UNLEADED 2 LEADED ❑7D, A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ S ❑5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE I } D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#, HAZARDOUS SUBSTANCE STORED&C.A.S.0 Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,e,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEA ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑6 Ion METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ I D 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 10096 METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 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 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A U 9 100%METHANOL COMPATSLE FRP A 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 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P 5 6 PRECISIONTESTING P 5 7 PRESSURETESTING P S 91 NCNE P S 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED{MOlYR} :1��-. ESTIM�ATEDANTITY OF INERT MATERIAL? ❑YES ❑ NO MAINING IN GALLONS THIS FORM HAS BEEN COMPLETED TINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# COUNTYf# JURISDICTION# AGENCY# i1 V Fo LLLJ CURRENT LO L AGENCY FACILITY ID# APPRO D B NA E PHONE#WITH AREA CODE PERMIT NUMBER PET APPROVAL DAT PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE MT. FEE CODE RE EIPT# BY: LITJS FORM 'A', ',UNLESS A CURRENT FORM`A' HAS BEEN FLED FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A ATA PROCESSING