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STATE OF CALIFORNlib WATER RESOURCES CONTR OARD <br /> FORM V: UNDI ROUND STORAGE TA m�Y„t M1 <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT, 40 - <br /> HANGE OF INFORMATION 7 PERMANENTLY CLONE ITEM �2 INTERIM PERMIT �4 AMENDED PERMIT6 TEMPORARY TANK CLOSURE 8 TANK REMOVEDFARM TANKYES❑ <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: r <br /> 10 <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- SPECIFY <br /> A. OWNERS TANK ID# - B. MANUFACTURED BY: �1ek <br /> C. YEAR INSTALLED -7 D. TANK CAPACITY IN GALLONS: <br /> A <br /> 11. TANK CO NTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CA <br /> B C. ❑ 1 UNLFADED LEADED 3 DIESEL <br /> A. MOTORVEHICLE FUEL �Z PETROLEUM <br /> 3 CHEMICAL PRODUCT 4 OIL <br /> PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN 2 WASTE 7 METHANOL �99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A),1q C.A.S.#: f✓ j!/ <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# /T <br /> ><III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D <br /> EOUBLE WALLED 3 SNGLEWALLED WfIH E%TERIORUNEA95 UNKNOWN <br /> NG WALLED 4 SECONDARY CONTAINMENT99 OTHER <br /> TEEUIRON Lj2 STAINLESS STEEL �3 FIBERGLASS �4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC <br /> ONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8180%METHANOL COMPATIBLE RIP <br /> 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> RONZE <br /> 1 RUBBER LINED 2 A MING 3 EPDXY LINING 4 PHENOLICUNING <br /> C.INTERIOR UNLINED C. UNKNOWN <br /> LINING ❑5 GLASS UNING <br /> IS LINING MATERIAL COMPATIBLE WITH RIO%METHANOL? YES NO 99 OTHER <br /> ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT E]3 VI P <br /> 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION <br /> PROTECTION �5 CATHODIC PROTECTION E]91 NONE UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE p 1 SUCTION A U 2 PRESSURE <br /> A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER <br /> p U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FISERGLASSPIPE <br /> C. MATERIAL A V y GALVANUMNIZED ED STEEL A ICUNKNOWN A U 99SOTHERTEEL �O W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> v p' P B 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> S <br /> 'N'a P 6 PRECISION TESTING P S T PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANKFILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? E]YES 0 NO <br /> SUBSTANCE REMAINING IN GALLONS <br /> THIS FOrAPPL <br /> HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> D <br /> CANT <br /> 'SNAMEE(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION M AGENCY# <br /> FACILITY IDM TANK ID# <br /> � = � � � v � / <br /> APPROVED BY NAM -" WITH AREA CODE <br /> CURRENT LOCAL AGENCY�F�ILITY D# C] C.� <br /> PERMIT NUMBER CC// PERMIT APPROVAL DATE PERMITEXPIRA ION D, / <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT# BY: <br /> FORMB(3-7-88) THIS FORM MUST BE ACCOMPANIE BYAFACILITY DIATAPPLICATION,A PROCESS NOR APA',UNLESSt,dRENT FORMA' HAS BEEN FILED <br />