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STATE OF CALIFORNUS WATER RESOURCES CONTRO ARD <br /> FORM V: UNDERGROUND STORAGE TANK PRO TON . ' q <br /> NM <br /> TANK PERMIT APPLICATION INFORMAI <br /> TAN■�[_ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ""' 10 <br /> MARK ONLY I NEW PERMIT <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FARM TANK-YES NO <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD <br /> B. MANUFACTURED EfY: <br /> Zi <br /> A. OWNERS TANK ID# <br /> / D. TANK CAPACITY IN GALLONS: <br /> C. YEAR INSTALLED J <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.i),IS NOT MARKED,COMPINLLETE <br /> E ITEM 2 LEADED 3 DIESEL <br /> FD. IF <br /> 1 MOTOR VEHICLE FUEL 2 PETROLEUM <br /> Ei. <br /> 1 PRODUCT ]4 GASAHOL E] 5 JET FUEL 8 AVIATION GAS <br /> 3 CHEMICAL PRODUCT 4 OIL 0 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW} <br /> 80 EMPTY 0�y 95 UNKNOWN 2 WASTE <br /> 5 HAZAHD0 LJOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&CA S.# <br /> IIL TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> F7;0 <br /> DOUBLEWALLED3SINGLEWALLEDWITHEXTERIORLINER El95UNKNOWN <br /> SINGLE WALLED4 SECONDARY CONTAIN NT ❑ 99 OTHER <br /> STEELIIRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLADWIFVBERGLASSREINFORCEDPLASTIC <br /> K 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM $100%METHANOL COMPATIBLE FRP <br /> MATERIAL 0 9 BRONZE El 95 GALVANIZED STEEL 95 UNKNOWN fl 99 OTHER <br /> 1 RU88ERLINEQ <br /> 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR 5 UNLINED E:] 95 UNKNOWN <br /> LINING 1 5 GLASS LINING <br /> 71- <br /> IS LINING MATERIAL COMPATIBLE ITH 100%METHANgL? �YES a NO �99 OTHER_ <br /> 4 FIBERGLAS REINF CED PLASTIC <br /> 0. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT 0 3 VINYL WRAP ` <br /> PROTECTION [-] 5 CATHODIC PROTECTION 0 91 NONE D 95 UNKNOWN 99 OTHE <br /> IV. PIPING INFORMATION CIRCLE A IF AB VE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE <br /> A U 1 SUCTION A U'2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUHLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL-/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVCJ <br /> U' 4 FIBERGLASS PIPE A U 91 NONE <br /> A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> C. MATERIAL A U S ALUMINUM <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> p 5 1 VISUAL GH£GK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELL S 4 ELECTRONIC MONITOR P S 99GROUNDWATEROMDNITORING WELLS <br /> P S 8 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3, wASTANKFILLEowITH <br /> r!t77:::��SUSSTANCENTITY G I INERT MATERIAL? YES NO <br /> MAINING IN GALLONS <br /> THIS FOLAaICANT'S <br /> HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW E DGE,IS TRUE AND CORRECT. <br /> NAME(PRINTED&SIGNATURE) y' QU <br /> �l7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> APPROVED 8T NAME PHONE WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> \ CHECK k PERMIT AMOUNT SURCHARGE AMT. Ll <br /> FEE CO A&CEIPT# BY, <br /> FORM B(a-z9-8a) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />