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STATE OF CALIFORf,\ WATER RESOURCES CONTL, BOARD ,•�„ �, FORM V: UNDERGROUND STORAGE TANK PROGRAM =� ' TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. � MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 5RMANENTLY CLOSED TANK I C ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO n. 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: Ki C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: -doo 11. TANK CO ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. E] 1 UNLEADED LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL RODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA.S.# CA.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1BLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM LE WA ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL El CONCRETE F-16 POLYVINYL CHLORIDE 1 ALUMINUM 8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR 1 RUBBER LINED El2 A ING El3 EPDXY LINING F-14 PHENOLIC LINING LINING ❑5 GLASS LINING NUNED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 10016 METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAP GR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHOOIC PROTECTION rj�j1 NONE ❑%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 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 U 95 UNKNOWN A U 99 OTHER A U I STEELPRON 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 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 095 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. �PI VISUALCHECK P S 2 INVENTORY RECONCILIATION P E WELLS P S 4 ELECTRONIC MONITOR P S 5 GRUND WATER MONITORING WELLS PRECISiONT£STING P 3 7 PRESSURETESTING S 91 ONE P S 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 GALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? El YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION# AGENCY# FACILITY ID# TANK ID# lei 10 IA I yl 6 1 -71 10 IOTO-1�4 CURRENT LOCAL AGENCY FACILITY ID# APPROVE BY NAMEw .PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE IT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM`A',UNLESS A CURRENT FORM-N HAS BEEN FILED DATA PROCESSING COPY