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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM ' "f TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O MARK ONLY all, NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ey TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK IDp B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q 11. TANK qONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C4 A, 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED EK3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL B. 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&C.A.S.# C.A.S.#: 411. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D 1 BLE WALLED ❑3 SINGLE WALLED WITH DXIERIOR LINER ❑ 95 UNKNOWN A TYPE OF U. SYSTEM 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 21 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONGETE ❑6 POLYVINYLCHLORIDE ❑ 7 UMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RIBBER UN® ❑2 ALXYD LINING ❑3 EPDXY UNING ❑ HENOLIC UNING LINING ❑ 5 GLASS LINING ❑6 UNUN® 95 UNKNOWN ❑ IB LINING MATERIAL COMPATIBLE WITH 100%MEfH4NOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT �VIWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORM ION CIRCLE A WASOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE Aky 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER IL CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A4 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION, YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S A,L CHECK 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS '{ CI SION TESTING S 1 PRESSURE TESTING P 8 91 NONE- P 8 95 UNKNOWN P 8 99 OTHER VI. INF RMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [DNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 16)lo U I o 1 U / CURRENT LOCAL AGENCFACILITY ID# APPROVED BY AME PHONE#WITH AREA CODE <D G.'zo 8 ek- A64--< PERMIT NUMBER PERAL DjTE,74PERMIT EXPIRATION DATE �Y SII( CHECX# PERMIT AMOUNT I SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B I3-reel THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED 'DATA PROCESSING COPY