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STATE OF CALIFORSA WATER RESOURCE,$,CON*L BOARD •`' ' FORMV:. UNDERGROUND STORAGE TANK PROGRAM TANK NK PERMIT APPLICATION INFORMATION T^NK COMPLETE ASEPARATE FORMWITH THE FOLLOWING if��FIMATION FOR EACH TANK. ;:. I Q MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ��' W ONE ITEM '❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED C FACILITY/$ITE NAME WHERE4ANK IS INSTALLED: 61,L) t:,), 11(.J q FARM TANK-YES❑ NO W i'� CJl I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W A. OWNERS TANK ID q ; B. MANUFACTUREDBY: / 00 C. YEAR INSTALLED z r- C D. TANK CAPACITY 1N GALLONS: G�C� IL TANK PONTENTS IF(A.t),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 1. C. ❑ 1 UNLEADED ❑ 2 LEADED G DIESEL ` ❑ 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 HAZARDOUS SUBSTANCE STORED 9,C.A.S.q C rf CA S N- CtL— I III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOLT A.B,C,e D A.TYPE OF ❑ I WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEMEZI-fALLED ❑ I SECONOAWCONTAINMENT ❑ 99 OTHER f7fli'STEELARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK �I 5 TE El6 POLYVINYL CHLORIDE F-17 ALUMINUM ❑ 6 1M METHANOL COMPATIBLE FRP MATERIAL © 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ I P N�LIC LINING C.INTERIOR LINING ❑6 GLASSUNIIIG ❑ 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%"00 ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 OHASPHALT ❑ 3VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC t PROTECTION ❑ 5 CATHODIC PROTECTION ff9I NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF A13OVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A: 2 PIIESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 1 LNGo WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A USTEEL/IROY> A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 'U s CONCRETE A U 7 STEEL OLAP W/FRP A U a 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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 B 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P B a PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED pATE LAST USED(MQ/YR} 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO "LLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATUHE) DATE LOCAL AGENCY USE ONLY COUNTY Y JURISDICTION A AGENCY# FACILITY ID 0 TANK ID M zc ' c� = CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE N WITH AREA CODE P 0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 0 PERMIT AMOUNT RCHARGE AMT. FEE CODE EIPT M BY: 7 - FORM B(a-z9-aa) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM `A*,UNLESS A CURRENT FORMA' HAS BEEN FILED (IATA 0T3e% `CCC -'—^--"