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STATE OF CALIFOR►"A WATER RESOURCES CONT 1L BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY El NEW PERMIT [-] 3 RENEWALPERMIT 10 ❑5 CHANGE OF INFORMATION 7 ANENTLYC T K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 6 p ARM TANK-YES❑ NO (� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 2 A. OWNERS TANK ID p B. MANUFACTURED BY: 00 G YEARINSTALLED D. TANK CAPACITY IN GALLO IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.l),IS NOT MARKED,Cp4PLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL 3 CHEMICAL 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. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.p CA.S.p: III. TANK CONSTRUC ON MARK ONE ITEM ONLY IN BOX A.B.C.A D A TYPE OF ❑ BLL WALLED ❑ 3 SINGLE WALLED WITH EI(IERIOR LINER ❑95 UNKNOWN SYSTEM 2 SI LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEELIIRON [:]2 STAINLESS STEEL ❑3 FIBERGLASS El 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK I MATERIAL El5 CONCRETE E]6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E]8 ION,METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑ 4 IC NING LINING ❑5 GLASS LINING ❑fi UNLINED 95 OWN ❑ S UNING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑NO OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT 3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE &195 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 AU UNKNOWN A U 99 OTHER B. CONSTRUCTION A ? 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 9 UNKNOWN A U 99 OTHER A&U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIB LASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 6 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' E]YES D 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY p JURISDICTION p AGENCY p FACILITY ID 0 TANK ID N CURRENT LOCAL AGENCY FACILITY ION APPROVED BY NAME PHONE N WITH AREA CODE 5� 03 v PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 9 PERMIT AMOUNT SURCHARGE AMT. FEE CODE IRECEIPT N BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY