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STATE OF CALIFORN�, WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM ;�Aa TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL ONE ITEM El2 INTERIM PERMIT F-] 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O m ARM TANK-YES❑ NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: ( FN CA) 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ((� A. OWNERS TANK ID# B. MANUFACTURED BY: µ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.7),IS NOT MARKED,COMPLETE ITEM D. A. F-11 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED [-] 3 DIESEL F-] 3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑<GASAHOL ❑ 5 JET FUEL F-16 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY 915 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. C.A.S. A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a o A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WAULD ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLAS9 REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 UMINUM ❑8100%METHANOL COMPATIBLE FHP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑89 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 P OUC LINING C. INTERIOR LINING ❑ 5 GLASS UNING F-16 UNLINED UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETILENEWRAP ❑2 TM OR ASPHALT ❑3 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHERIV. 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 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE II C.MATERIAL A U 5 ALUMINUM A ONCREM A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING 42l NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTL CLOSED IN PLACE 1.ESTIMATED D TE LAST USED(MO/YR) 2.ESTIMATEDIOUANTITY OFNB� 3.WAST K FILLED WITH A SUBSTA R MAIMING IN �w 1 q�ERIAL? ❑YES [-] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY 01 PERJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# D 10 'Z— '2— U v 15 1 1 CURRENT LOCAL AGENCY FACILITY ID# APPROVE BY NAME PHONE#WITH AREA CODE G 2 / ZL &?NJ PERMIT NUMBER PERMIT APPROVAL DATE PER EXPIRATI NDA CHECK# PERMIT AMOUNT SURCHARGEANT. FEE CODE RECEIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIEd e7Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A BENT FORMA' NAS BEEN FILED DATA PROCESSING COPY