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STATE OF CALIFORFM WATER RESOURCES CONTS BOARD <br /> FORM V: UN GROUND STORAGE TANK PR RAM D <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. m � <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEMCHANGE OF INFORMATION 7 PERMANENTLY CLOSED`TANK <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ' <br /> P/G(� FARM TANK-YES D NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: (� CD <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: <br /> IL TANK C:IMTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. MOTOR VEHICLE FUEL 0 2 PETROLEUM B. C. ❑ 1 T <br /> 2 LEADED IESEL <br /> 3 CHEMICAL PRODUCT D 4 OIL PRODUCT ❑4 D 5 JET FUEL D 6 AVIATION GAS <br /> 5 HAZARDOUS D 80 EMPTY D 95 UNKNOWN 2 WASTE 7 ] 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF ❑ 1 OQUBLE WALLED 0 3 SINGLE WALLED WITH WERIOR LINER 95 UNKNOWN <br /> SYSTEM LLtl SINGLE WALLED 0 4 SECONDARY CONTAINMENT 99 OTHER <br /> STEEL/IRON 0 2 STAINLESS STEEL. D 3 FIBERGLASS E:]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B'MATERIAL D 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM 8100%METHANOL COMPATIBLE FRP <br /> ❑9 BRONZE D 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED WE 2 A DLINING 3 EPDXY UNING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS UNING UNUNED 95 UNKNOWN <br /> IS UNING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES 0 NO Qd90THER- kk <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP 02 ROR ASPHALT 3VINYL WRAP 04 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 1 NONE 0 95 UNKNOWN D 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE ju SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION 'U4 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A Al I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A Ni�5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATEDDATELASTUSEDWO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WRH <br /> SUBSTANCE REMAINING IN INERT MATERIAL? E YES E NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> ,C,OUNTYUNTYY## JURISDICTION# AGENCY# FACILITY ID# <br /> TANK ID# <br /> 3 1 C� <br /> LCURRENT LOCAL AG NCY FACILITY ID# APPROVED BY NAME <br /> A_ <br /> PHONE#WITH AREA CODE <br /> oAl <br /> IT NUMBER (� PERMIT APPROVAL DATE P RMIT EXPIRATION DATE <br /> ` K# PERMIT AMOUNT SURCHARGE AMT. FEE CODE <br /> IAV11 RECEIPT p By, <br /> FORME(62988) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />