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STATE OF CALIFORNIi WATERRESOURCES CONTRCOOARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 FORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8�-YESD � FARM TNO N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 'N � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY B. MANUFACTURED BY: OD A. OWNERS TANK 10# D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B Q ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL A. F-11 MOTOR VEHICLE FUEL F] 2 PETROLEUM ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL E] 6 AVIATION GAS ❑ ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑1 DOUSLP WANED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED [:]4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELARON ❑2 STAINLESS STEEL 3 RBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR 5 GLASS UNINGfi UNLINED ❑95 UNKNOWN LINING ❑ ❑ ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHIENEWRAP ❑ 2TAR OR ASPHALT ❑3VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 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 STAINLESS STEEL A U 3 POLYVIWLCHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE D W/FRP A U B 100%METHANOL COMPATIBLE FAP C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLA 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. S IVISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? DYES [:] NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANTS NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY C OjjUNTY]]# JURISDICTION FACILITY ID# TANK ID# Cm � AGEL_J--❑ CURRENT LOCAL AGEN Y FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT APPROVAL DATE or 0 PERMIT EXPIRATION DATE PERMIT NUMBER CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT I le ORM B(6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CU RENT FORMA HAS BEEN FILED DATA PROCESSING COPY