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STAT ALIPORNI WATER RESOURCES CONTR OARD ,.•��;-0 <br /> FORM V: UND ROUND STORAGE TANK PR AM ` <br /> TANKI TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .P <br /> MARK ONLY PERMIT ®3 RENEWAL PERMIT []30'5CHANGE OF INFORMATION F-17 PERMANENTLY CLOSED TANK- <br /> ONE <br /> ITEM 2 INTERIM PERMIT 4 AMENDED PERM)T 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED jv <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED ARM TANK-YES® NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOW -SO SPECIFY 1 <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: _ <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: L- <br /> CA) <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F-A" <br /> �� �' <br /> A. L'_J ' MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. [:] 1 UNLEADED E'�LEADED �3 DIESEL <br /> - 3 CHEMICAL PRODUCT 4 OIL 2 PRODUCT �4 GASAHOI -15 JET FUEL �6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY E]95 UNKNOWN E]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.# C.A.S.q: <br /> xII1. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,Ac D <br /> A.TYPE OF Di DOUBLE WALLED D 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM [-]2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL �FIBERGLASS 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL �5 CONCRETE E]6 POLYVINYL CHLORIDE F--j 7 ALUMINUM F�8 100%METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 0 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED 2 JLKYD LINING F-13 EPDXY LINING El 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING UNUNED 9Y UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100016 METHANOL? ❑YES t?9 [:]99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP 0 2 TAR OR ASPHALT 3 VINYL WRAP �4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION E]91 NONE ®95 UNKNOWN [:]99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOA GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) W4 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 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 /> PS 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3"DOSE WELL S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 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 /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES [::] NO <br /> THIS FORM HAS BEEN CO LE ED UNDER PENALTY OF ERJURY, ND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLIRINDBSIGNATURE)/ � DATE <br /> M /6 <br /> LOCAL AGENCY USE ONLY <br /> [PE <br /> OUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> NT LOCAL AG NCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> /4 ,3 / jf <br /> NUMBER PERMIT APPROVAL DATE MITE (RATION D <br /> # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMP of A FACILITY/SITE APPLICATION, FORM`A',UNLE, --RENT FORMA HAS BEEN FILED �o <br /> DATA PROCESSIMn( nov I <br />