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STATE OF CALIFORK., WATER RESOURCES CONTRk,.,30ARD FORM V: UNDERGROUND STORAGE TANK PROGRAM `_ TANK TANK PERMIT APPLICATION INFORMATION �% COMP TE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY EW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLYCLO TANK ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: F x FARM TANK-YES NO W N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY OD A. OWNERS TANK IDNQ 3' B. MANUFACTURED BY: C. YEAR INSTALLED 3 D. TANK CAPACITY IN GALLONS: j U DO U II. TANKCONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ffl I MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED 1:12 LEADED DIESEL F-1B.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 � A HAZARDOUS SUBSTANCE STORED&C.AS.# W C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOA A,B,C.6 D I WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN A.TYPE OF ❑ SYSTEM Ll 2 SINGLEWAILFD ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEDURON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZB)STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 FUSBERUNED ❑ UNING ❑3 EPDXY LINING [__j4 PHENOUCLINING LINING F-15 GLASSUNING 6 UNLINED ❑ 95 NOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER 1�✓+Y✓,v D. CORROSION ❑ I POLYETHLENEWPAP 2TAR ORASPMALT ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORM ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINL.ESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 11_6 CONCRETE A U 7 STEELCLADW/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A&V95 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 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 'SIS PRECISION TESTING P 8 7 PRESSURE TESTING P 6 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE kET USED(MO/YR) 2. ESTIMATED GUANTITY OF 3.WAST NK FILLED WITH I SUBST NC INING IN GALLONS I E TERIAL7 ❑YES ❑ NO THIS FORM FIAS 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 C�OUNTYY* JURISDICTION# AGENCY# FACILITY ID# TANK ID# ' � ' 3 I / I ( o loD 3 CURRENT LOCAL AGENCY FACILITY ID# APPR D BYME PHO E#WITH ARE COD PEP IT HN UGER v PE IT A PROVAL DAT PERMIT EXPIRATION DA �f1L L4 CHECKx PERMIT AMOUNT SUflCHA GEA T. IF FEE CODE RECEIPT BY: FORM H 15-29HHI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNI 1A CURRENT FORMA' HAS BEEN FILED DATA PRl1CF5.SIN4: rnov