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t::+;'""•'p+ 5W7--7- 7IT,7..STATE OF,CALIFORNI WATER RESOURCES CONTRqWARD P ue[[ A FORMV:: ROU TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I MARK ONLY 1 NEW PERMIT �3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED Loa rx) FACILITY/SITE NAME WHERE TANK IS INSTALLED: ' r FARM TANK-YES❑ NO wo 1. 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 22NTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A Y MOTOR VEHICLE FUEL ® 2 PETROLEUMB. C• ® 1 UNLEADED E] 2 LEADED E]3 DIESEL 3 CHEMICAL PRODUCT 4 OIL E2fl PRODUCT ®4 GASAHOL ❑ 5 JET FUEL F1 6 AVIATION GAS 5 HAZARDOUS ❑80 EMPTY 0 95 UNKNOWN ❑ 2 WASTE 0 7 METHANOL E] 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.#: I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C, D A.TYPE OF R2117DOUBLE WALLED F--j 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ®2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON 2 STAINLESS STEEL ®3 FIBERGLASS 4PEL 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 KNOWN ❑99 OTHER C.INTERIOR 1 RUBBER LINED F-]2 ALKYD LINING E2"3EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 7 6 UNLINED F-1 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ®2 TAR OR ASPHALT ®3 VINYL WRAP [2"4'FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION 91 NONE ®95 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 0PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED U 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) A 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 A& 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. P S 1 VISUAL CHECK Po 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 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 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) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# -1 EEFACILITY ID# TANK ID# [ET I I =-] Ul 07o 1 (9 1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED NAME PHONE#WITH AREA CODE ®r f PERMIT NVMBER PER/MIIT OVAL DAT6 PERMIT EXPIRATION DATE If CHECK# PERMIT AMOUNT SURCHARGE T. FEE CODE RECEIPT# BY: FORM B 6-29-88 THIS FORM MUST BE ACCOMPANIWBY A FACILITY/SITE APPLICATION, FORM ` ' UNLESS` URRENT FORM`A' HAS BEEN FILED DATA PROCESSINGY t :