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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM =" TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 12<1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z ARM TANK-YES❑ NO�kgl Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK IDR B. MANUFACTURED BY: V A41<', C. YEAR INSTALLED111/ D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. IV A. Xi MOTOR VEHICLE FUEL 2r2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL 1 ' ❑3 CHEMICAL PRODUCT ❑ 4 OIL 5<1 PRODUCT ❑<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.R C.A.S.W XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,B,C,&D A. TYPE OF 1DOUBLE WALLED ❑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 F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE MATERIAL ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ 8 IW%MERUNOLCOMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING F-14 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑8 UNLINED �95 UNKNOWN ANO ❑ISUNINGMATERIAL COMPATIBLE WITH 100%METHL? ❑YES 0 N 99OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3WM'LWRAP ❑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 APPLI BLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSUflE A U 3 GRAVITY A U 9 OTHER S.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A V STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIOE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. y8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 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 UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH k O!V SUBSTANCE REMAIN G IINERT MATERIAL? ❑YES NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TIED THE BEST OF MY KNOWLEDGE,IS TRUE AND CORREC . ,APPLICANT'S ED&SIGNATUR DATE �¢ X LOCAL AGENCY SE ONLY COUNTY k JURISDICTION M AGENCY k FACILITY ID R TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE a WITH AREA CODE � 2 GH- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EX RA ION 2E I�J/ CHECK* PERMIT AMOUNT A.SURCHARGE AMT. FEE CODE I RECEIPT N BY: III `71T CCOIIANIEDBY A FACILITY/SITE APPLICATION,(3-7-88) THIS FORM MUST BE; , FORM 'A,,UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY -�{