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STATE OF-CALIFORN WATER RESOURCES COI I OARD FORMV: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FOM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I MARK ONLY ❑ 1 NEW PERMIT3 RENEWAL PERMIT ®5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TA ONE ITEM E]2 INTERIM PERMIT [:]4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM Vl C. 1 UNLEADED ❑ 2 LEADED EV DIESEL 7 3 CHEMICAL PRODUCT [:] 4 OIL DUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ®2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# Ng C.A.S.#: II(. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A,B,C,&D A.TYPE OF ❑ 1,09UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM EglSINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER STEEL/IRON ®2 STAINLESS STEEL ®3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ®5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ®8 100%METHANOL COMPATIBLE FRP MATERaaL' ❑9 BRONZE ® 10 GALVANIZED STEEL ❑95 UNKNOWN ®99 OTHER ® 1 RUBBER LINED ®2 A D LINING ❑ 3 EPDXY LINING ®4 PHENOLIC LINING C.INTERIOR 11 I LINING ❑5 GLASS LINING UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] NO ❑99 OTHER D.CORROSION ❑ i POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI L WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE L1215 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A t SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A' 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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. -05 P S 1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 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 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) ATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# r. 061 / 10AI :10M CURRENT LOCAL AGENCY FACILITY ID# APPRO Y PHONE#WITH AREA CODE F PERMIT NUMBPRPERMIT APPROVALDATE PERMIT EXPI TIQN O T'E' CHECK# PERMIT AMOUNTSURCHAR FEE CODE R CEIPT# BY: I I' Ail FORM B'(6-29-8a) THIS FORM MUST BE aCCOMPANIE A FACILITY/SITE APPLICATION, FOR `A',UNLESS A RENT FORM'A' HAS BEEN FILED DATA PROCESSING __ ?