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STATE OF CALIFORNIA WATER RESOURCES CONTROVIOARD FORM V: UND ROUND STORAGE TANK PRO AM COMPLETE TANK TANK PERMIT APPLICATION INFORMATION TANK. A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH MARK ONL� 1 PERMIT ❑ 3 RENEWAL PERMITHANGE OFINFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOV FACILITY/SITE NAME WHERE TANK ISSTALL I�Q�� FARM TANK-YES❑ NO IN0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPEC Y A. OWNERS B. MANUFACTURED B ZIP C. YEAR INSTALLED N G D. TANK CAPACITY IN GALLON .g Q 00 DO II. TANK COtITENTS IF(A.1),IS MARKED,COMPLETE IT C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F613 TOR VEHICLE FUEL ❑ 2 PETROLEUM B /O C. ED] 1 UNLEADED EADED ©.8'6ESEL EMICAL PRODUCT ❑ 4 OIL �ODUCT Q ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME O / ,y G.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# A2, All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A TYPE OF ❑ 100 LE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTE ��' ZINC ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE p 7 ALU M ❑8190%METHANOL COMPATIBLE FRP MATERI ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYO UNING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C' INTERIO ❑5 GLASS LINING ❑6 UNLINED �NKNOWN LINING /b ❑ [e IS MATERIAL COMPATIBLEWRH 100%METHANO I/ ❑YES NO ❑ 99 OTHER D.CORROSI ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINY RAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECT❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFO ATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTIO A l SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER !Ll A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL /�l A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 190%METHANOL COMPATIBLE FRP V A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER to. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. -�I P 4 1 VISUAL CHECK VS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS IJ p PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED( 0/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 2 �I/ �'// /- GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO 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 IDR ffffmz OVED E ONE N WITH AREA CODE E!:; ILITY Sd?V L/ Pf�1(IT APPROVA✓D/ATE PERMIT EXPIRAT16N DATE AMOUNT SURCHAARRG�EEAMT. FEE CODE RECEIPT# BY: C\ FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM `A',UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY