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E A I C ur CALIFONM14 WATER RESOURCES CONTNOL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM QO TANK / TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARIATE FORM WITH THE FOLLOWING RMATION FOR EACH TANK. MApK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ONE ITEM 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑<AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANKDESCRIPTION COMPLETE ALLITEMS-IFUNKNOM 11 SO SPECIFY FARM TANK-YES❑ NO O C�37 A. OWNERS TANK ID p i i R. MANUFACTURED BY: C. YEAR INSTALLEDTTT D. TANK CAPACITY IN GALLONS: !�D II. TANK CO TENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I OTOR VEHICLE FUEL ❑2 PETROLEUM B. 3 CHEMICAL PRODUCT C] p OIL C. ❑ I UNLEADED ❑2 LEADED 3 DIESEL ❑ ❑ 5 HAIAp0005 e0 EMPTY ❑ 1 PRODUCT ❑4 GASAMOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ ❑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 A C.A.S.N III. TANK CONSTRUCTION MApK ONE ITEM ONLY IN BOX A,B,C,&D CA.S.N: A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED KITH EXTEROR LINER SYSTEM ❑$SINGLE WALLED ❑/SECONDARY CONTAINMENT ❑ UNKNOWN ❑99 OTHER B.TANK ❑ I STEEURON ❑2 STMNLEMSTEEL ❑3 FIBERGUS$ 4 STEEL CLAD MUTE ❑5 CONCRETE ❑6 POI.YWNYL CMLORDE ❑ 7 ALUMINUM ❑B 100A METF1AryWOl COMPATIBLE EIFISERGLASS RP NFORCED FUSTIC ❑9 BRONZE ❑ 10 GALVANIZEO STEEL ❑95 UNKNOWN ❑99 OTHER C INTERIOR ❑ 1 RIBBFA UNEO ❑2 ALKYD LWINO ❑3 EPO%YUNING ❑1 pHENOLICUNING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOVIN ❑IS UNWG MATERIAL CUMPATIBLENTH TOOK METWINOL7 ❑YES ❑NO ❑ %99 OTHER D. CORROSION ❑ I POLYETMLENE WRAP ❑2 TAR ORASPHALT 3 VINYL WRAP PROTECTION ❑5 G1FN101C PROTECTION ❑91 NONE ❑K FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN E 99 OTHER IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A u 1 sucno0=1 A u z PREssuRE B.CONSTRUCTION A U VITY A U 91 NONE A U 95 LINK WN A U 99 OTHER I 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 I FIBERGLASS PIPE A U 91 NONE C' MATERIAL A U S ALUMINUM A U 2 CONCRETE A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 7 STEELCLADAD W/FRP A U B 100%METHANOL COMPATIBLE FRP 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 6 1 VISUAL PRECISION TE P S 2INVENTORY RECONCILMTION P g 3 YADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P B B PRECISION TESTING P g 7 PRESSURE TESTING Pg 9/ NONE P S 95 UNKNOWN P 6 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED GATE LAST USED(MO/Yfl) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH GALLONSINERT MATERIAL? E]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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNrrr / ITTI'''J'URIIIS'DI�CTION N AGENCY N FACILITY ID N� TANK 10 N / CURRENT LOCAL AGENCY FACILITY 101 M APPROVED BY NAPE PHONE 1 WITH AREA CODE PERMIT NUMBER / PERMIT APPROVAL DATE PERMIT E%PIRATION DATE CHECK/ PERMIT AMOUNT SURCHARGE ANT. d FEE CODE RECEIPT BY: ! FORM B I6-z9-BBI THIS FORM MUST BE ACCOYPANIE A FACILITY/SITE APPLICATION, FORM ' '.UNLESS A CURRENT FORMA' NAS BEEN FILED/ DATA PROCESSING COPY