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STATE OF CALIFORNI/o WATER RESOURCES CONTROARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I RMATION FOR EACFI TANK. ZO MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM E]2 INTERIM PERMIT [—]4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED FARM TANK-YES❑ NO W FACILITY/SITE NAME WHERE TANK IS INSTALLED: (D I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED1 4 AAJ D. TANK CAPACITY IN GALLONS: 11. TANK CPWENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B. C. ❑ 1 UNLEADED 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM LEADED ❑ ❑3 CHEMICAL PRODUCT ❑ 4 OIL EEJ 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 C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIPON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC LINING C. IN NRGOR F-15 GLASS LINING F-16 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 100%METRANOLP ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHER A U i STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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. S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS p"' S 6 PRECISION TESTING P S 7 PRESSURE TESTING 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 HA 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# FACILIUEE URLI E= TY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RMIT E (RATION DA TE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B(6-29-8a) THIS FORM MUST BE ACCOMPANIEL JY A FACILITY/SITE APPLICATION, FORM `A',UNLESS i!5RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY