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STATE OF CALIFORNIJ WATER RESOURCES CONTRO ARD <br /> FORMV:: UNDERGROUND STORAGE TANK PRO AM <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 EZ u CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT D 6 TEMPORARY TANK CLOSURE Q 8 TANK REMOVED <br /> FACILITY/SITE NAME INHERE TANK IS INSTALLED: 2 3 , -SC4" FARM TANK-YES 0 NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 <br /> A OWNERS TANK ID q <br /> B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Cti h <br /> �. <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. MOTOR VEHICLE FUEL F-� 2 PETROLEUM B. C, I V <br /> 1 UNLEADED 2 LEADED 3 DIESEL r� <br /> 3 CHEMICAL PRODUCT �4 OIL El 1 PRODUCT 0 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS ❑ 80 EMPTY D 95 UNKNOWN ASTE 0 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 3 C.A.S.N C.A.S.#: <br /> ><III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D <br /> A.TYPE OF Q 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT Q 99 OTHER <br /> Q 1 STEELIIRON 2 STAINLESS STEEL 3 FIBERGLASS 0 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK F-15 CONCRETE <br /> MATERIAL 6 POLYVINYL CHLORIDE T ALUMINUM Ej 8 10096 METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER <br /> C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING ® 3 EPDXY LINING ❑4 PHENOLIC LINING <br /> LINING 5 GLASS LINING 6 UNLINED E315 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES Q NO 99 OTHER <br /> D.CORROSION } POLYETHLENEWRAP 2 TAR OR ASPHALT 3VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE Ee<UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE KU21 SUCTION A U 2 PRESSURE 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 U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPAT18LE FRP <br /> A U 9 GALVANIZED STEEL AGU 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> PS I VISUAL CHECK o S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> fv4' SUBSTANCE REMAINING iN INERT MATERIAL? DYES ❑ NO <br /> GALLONS <br /> THIS FORA?HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME:(PRINTED$SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTC-Y�# JURISDICTION# AGENCY# EL5 <br /> 16111 / <br /> FACILITY ID# / / TANKID# <br /> r � 1 1:1 1 1 1 1 cls Il V I o I o I <br /> CURRENT,�°;�AL AGENCY FACILITY ID# APPROVED BY NAM PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> }` CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIW A FACILITY/SITE APPLICATION, FOR M `A',UNLESS A1510IENT FORM'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />