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STATE OFCALIFORNIA WATER RESOURCES CONTROL BOARD .. <br /> FORM V: UNDERGROUND STORAGE TANK PROGRAM o <br /> TANK CTANK PERMIT APPLICATION INFORMATION o <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. � z <br /> 10 <br /> MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F__j 7 PERMANENTLY C K <br /> ONE ITEM E]2 INTERIM PERMIT E]4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVEDW <br /> (� <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 9. /v/L eT �r r,,� TANK-YES❑ NO r'%) <br /> zol ry <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY q Q <br /> A. OWNERS TANK 1D 14 tt B. MANUFACTURED BY: W <br /> C.YEAR INSTALLED 6 y D. TANK CAPACITY IN GALLONS: (J fI <br /> 11. TANK CONTENTS IF(A-1),-18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. r__j 1 MOTOR VEHICLE FUEL EY2 PETROLEUM B. C. 1 UNLEADED r_-]2 LEADED EWDIESEL <br /> 3 CHEMICAL PRODUCT F-1 4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL F-1 6 AVIATION GAS <br /> 5 HAZARDOUS [-]80 EMPTY 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.11.. . C.A.S.It: <br /> 1 <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D <br /> A.TYPE OF DOUBLE WEE ❑3 SINGLE WALLED WITH EKTBIOR LINER ❑95 UNKNOWN <br /> SYSTEM RP2, NGLE WALLED O 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEUIRON 2 STAINLESS STEEL �3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIALL <br /> B.TANK D 5 CONCRETE r__j 6 POLYVINYL CHLORIDE F_�7 ALUMINUM [:]B 100%METHANOL COMPATIBLE FRP <br /> E]9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN E]99 OTHER <br /> i RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING n 4_PHENOLIC UNING <br /> C.LINING <br /> N INTERIORGIOR <br /> Ir__j 5 GLASS LINING 6 UNLINEDff'99 <br /> /UNKNOWN <br /> a IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES 0 NO OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3L WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E 5 CATHODIC PROTECTION 91 NONE %UNKNOWN 99 OTHER <br /> IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE _AU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A•U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 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 /> P 8 1 VISUAL CHECK . P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES NO i <br /> THIS FORM 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> ® 1 -71K] 1010101-3 <br /> CURRENT LOCAL AGENCY FACILI:r# APPROVED BY NAME PHONE M WITH AREA CODE <br /> 1 <br /> Q L W4A--. <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 3�g <br /> CHECK# PERMIT AMOUNT 'URCHARGE ALIT. FEE CODE EIPT# BY:1 , <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CUA+HENT FORD A' HAS BEEN FILED C <br /> nATA4 PF7tIf71R_`F_qSIMI*/ nPY ,­ <br />