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STATE OF CALIFOR WATER RESOURCES CONT OARD .A FORM V: UND GROUND STORAGE TANK PR RAM =o 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 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: - A FARM TANK -YES LU NO I. TANK DESCRIPTION COMPLETE ALL ITEMS- IF UNKNOWN -SO SPECIFY fl 11-5-3 / ` A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED b D. TANK CAPACITY IN GALLONS: lwoo TANK 06NTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D� A. Ml MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. 1 DOUBLE WALLED C. [:]I UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT F-14 OIL 1 PRODUCT ❑ 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. # C.A.S. #: III. TANK CONSTRI)&ION MARK ONE ITEM ONLY IN BOX A, B, C, & D IV. A. TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [:j!`8INGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A F-11 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 2 STAINLESS STEEL F-11 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 HENOUG LINING C. INTERIOR LINING ❑ 5 GLASS LINING F-]6 UNLINED 6 CONCRETE 95 UNKNOWN U 7 STEEL CLAD W/FRP ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO VOTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE L 'J 95 UNKNOWN ❑ 99 OTHER r�rm�a n'VrvnMJ% I wl'% UIHGLt A II' Abyyt UHUUNU, U IF UNULHUHUUNU, BOTH IF APPLICABLE 3. WAS TANK FILLED WITH A. SYSTEM TYPE A U 1 SUCTION A w 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A (U2 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 (PVC)U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP 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. 74 P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 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 TANK ID # SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO PHONE # WITH AREA CODE -11 Q21 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 & SIGNATURE) DATE LOCAL AGENCY LISE ONLY COUNTY # 9 JURISDICTION # AGENCY # FACILITY ID # 1�/� TANK ID # CURRENT LOCAL AGENCY FACT ID # Wct-5D/ APPROVED BY NAME PHONE # WITH AREA CODE -11 Q21 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE - fw CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (6-29-88) 1 MIU PUMM MUS I Bt ACCUMPANItU BY A FACILITY/SITE APPLICATION, FUNIVI 'A', UNLE11WCURRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY