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STATE OF CALIFORN% WATER RESOURCES CONT# ARD go FORMV: UNDERGROUND STORAGE TANK PROGRAMTANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK MARK ONLY ❑ ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 1 j ONE ITEM ❑ 2 INTERIM PERMIT FARM TANK-YES❑!NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: „) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SCIFY B MANUFACTURED BY'. CC A. OWNERS TANK 10# a' D. TANK CAPACITY IN GALLONS J V r7 C.YEAR INSTALLED /< Y i COMPLETE ITEM B IF (A.1),IS NOT MARKED COMPLETE ITS 2 II. TANK CONTENTS IF(A.1),IS MARKED, LEADED 3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM El 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL El AVIATION GAS ❑3 CHEMICAL PRODUCT ❑4 OIL 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ❑ UNKNOWN DOUBLE WALLED ❑3 SINGLE WALLED WITH EKTERIOfl UNER 95 A.TYPE OF ❑q SECANDARt COMAINMENi ❑99 OTHER SYSTEM �'G SINGLE WALLED ❑ i RRON Li2 STAINLESSSTEEL 3 FIBERGLASS ❑d STEEL CIADWIFlBERGIASS REINFORCED PLASTIC B.TANK F-15 CONCRETE CONCRETE ❑6 POLYVINYLCHLORIDE 7 YAAIUM8100%METHANOL COMPATIBLE FRP MATERIAL 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑9 BRONZE ❑ ❑1 RUBBER UNER ❑2 ALKYDUNING ❑ 3 EPDXY LINING I PyENOLIC LINING C.INTERIOR 6 UNLINED I^�,y55 UNKNOWN LINING ❑ I GLASS LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION 1 POLYETHLENEWRAP 2TAR OR ASPHALT 3V WRAP ❑4FlBERGlASS REINFORCED PLASTIC ❑ ❑ 5 UNKNOWN ❑ 99 OTHER PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. 0 IFUNDERGROUND,BOTH IF AAPPLIC�ABNONE A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY 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 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PIPE A U 91 NONE 8100%METHANOL COMPATIBLE FRP C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 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 8 1 VISUALCHECK IP/, 8 2 INVENTORY RECONCILIATION F 9 91VADOSE WELLS F NONE B 95EUNKNOWN LECTRONIC MONITOR PP SS 99 OTHER WATER MONITORING WELLS P S 6 PRECISIONTESTING P 8 7 PRESSURE TESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WASTANKFILLEO WITH 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? DYES ❑ NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTIONS AGENCY# FACILITY ID; TANKID= F=E m 1.� APPROVED BY NAME0 P 01 6L,A1 CODE CURRENT LOCAL AGENCY FACILITY IDX I L PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMPANX-0 BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C tRRENT FORM'A' HAS BEEN FILED FILE COPY