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STATE OF, ALIFORNIS WATERRCE CONTROSPARD FORMV: ,: U D TANK PROIAAM IrAkilt TANK PERMIT APPLICATION INFORMATION " COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT215"C HANGE OF INFORMATION ® 7 PERMANENTLY CLOSED NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED` I FACILITY/SITE NAME WHERE TANK IS INSTALLED: �:�/ 5 It'dANK -YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # 3 ]]ED. ANUFACTURED BY: V C. YEAR INSTALLED ANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (.1), IS NOT MARKED, COMPLETE ITEM Do A.KNOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C• ® 1 UNLEADED 2 LEADED � 3 DIESEL HEMICAL PRODUCT ❑ 4 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. 1F NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #:' III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B,C, & 2. ESTIMATED QUANTITY OF JURISDICTION # AGENCY # A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN PERMIT NUMBER SUBSTANCE REMAINING IN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER � NO PERMIT AMOUNT SURCHARGE AMT. GALLONS 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 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) B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 1�96METHANOICOMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING LINING C. INTERIORLINING 5 GLASS LINING F-]6 UNLINED IFf-]ENOUl NKNOWN U IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES 1:1NOTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT❑ 3 V WRAP El FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E]91 NONE 5 UNKNOWN 99 OTHER I.PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,' BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 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 U 2 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 A6 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. 8 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF JURISDICTION # AGENCY # 3. WAS TANK FILLED WITH I 1 1:1 E CURRENT LOCAL AGENCY FACILITY ID (7 PERMIT NUMBER SUBSTANCE REMAINING IN IT PERMAPPR01 INERT MATERIAL? [:] YES � NO PERMIT AMOUNT SURCHARGE AMT. 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 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF JURISDICTION # AGENCY # 3. WAS TANK FILLED WITH I 1 1:1 E CURRENT LOCAL AGENCY FACILITY ID (7 PERMIT NUMBER SUBSTANCE REMAINING IN IT PERMAPPR01 INERT MATERIAL? [:] YES � NO PERMIT AMOUNT SURCHARGE AMT. GALLONS LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # [M] I 1 1:1 E CURRENT LOCAL AGENCY FACILITY ID (7 PERMIT NUMBER IT PERMAPPR01 CHECK # PERMIT AMOUNT SURCHARGE AMT. FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPI DATA I FACILITY ID # ��-^] *I� TANK ID # Lalu oloo 6 1 1 1 T APPROVED BY NAME PHONE # WITH AREA CODE DATE PERMIT EXPIRATION DATE FEE CODE t EIPT# BY: .-./_ 4TIN; FOR 'N,UNLESS A CURRENT FORM `A' HAS BEEN FILED iCESSING COPY