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STATE OF CALIFORNI& WATER RESOURCES CONTR*OARD <br /> FORM V: UNDE GROUND STORAGE TANK PRO RAM �m <br /> TANK TANK PER IT APPLICATION INFORMATION ry <br /> C PLETE A SEPARATE F RM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O <br /> 1 NEW PERMIT 3 RENEWAL PL61 <br /> 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOD K <br /> MARK ONLY CA) <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED J <br /> ,! MTANK-YES❑ NOFACILITY/SITE NAME WHERE TANK IS INSTALLED: I <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> CA <br /> B. MANUFACTURED BY: <br /> A. OWNERS TANK ID# <br /> D. TANK CAPACITY IN GALLONS: ICI Q a <br /> C.YEAR INSTALLED <br /> II. TANK ONTENTS IF(A.t),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM <br /> 0 G ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT E 4 OIL <br /> 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPN 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.W <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> 1 UBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> A TYPE OF 99 OTHER <br /> SYSTEM 2 SINGLE WANED 4 SECONDARY CONTAINMENT <br /> 1 STEEUIRON 2 STAINLESS STEEL 3FIBERGLASS 44SSTTEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM n&40%METHANO� B E FRP F�A� <br /> MATERIAL 9 BRONZE E] 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER 6 <br /> 1l <br /> 1 RUBBERUNED 2 ALKYD LINING F-1 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR E]5 GLASS UNING 6 UNLINED 1U SOWN <br /> LINING <br /> IS USING MATERIAL COMPATIBLE WITH 100%METHANOL7 <br /> YES NO OTHER <br /> D.CORROSION ❑ I POLYEfHLENEWRAP 2 TAR OR ASPHALT n 3'IM'L WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFA E GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER <br /> U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A A 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SFn� <br /> IRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> / g 1 VISUAL CHECK PY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> 4U�LJ`� P S 8 PRECISION TESTING P TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF INERT MATERIAL? YES NO <br /> SUBSTANCE REMAINING IN GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FPERMIT <br /> # JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> L AGENCY FACILITY ID# <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> 576I <br /> R G PERMIT APP OVALOATE PERMIT EXPIRATION DATE <br /> I <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(6-29-83) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE <br /> APPLICATION, <br /> G <br /> FORM A ',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PRO <br />