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STATE OF CALIFORNI WATER RESOURCES CONTRO ARD FORM V: UNDE ROUND STORAGE TANK PRO G,4'AM f Y - � TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH'TANK. r MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED [ FACILITY/SITE NAME WHERE TANK IS INSTALLED. 1 N FARM TANK-YES❑ NO kr 4b. 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY '4 A. OWNERS TANK ID k 6 B. MANUFACTURED BY: y C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ©� 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED OMPLETE ITE A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL RODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS F-15 HAZARDOUS ❑ 80 EMPTY E]95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 9g OTHER{DESCRIBE IN ITEM D,BELOW} D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CA s.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY 1N BOX A,B,C,&D A TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B. TANK 1I ' STEELf fRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS AEAFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 1 DO%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING Pr5 UNLINED ❑95 UNl(NOW ❑ IS LINING MATERIAL COMPATIBLE WITH 1W%METHANOP ❑YES ❑ NO [�199 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP 1:1 4 FIBERGLASSREINFORCEOPLASTIC PROTECTION E5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A W 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 POLYVINYL CHLORIDE(PVC) A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEL CLAD W/FRP A A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER a 1009U METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �r- P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P g PRE CISIONN TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DA LAST USED(MOlYA) 2, ESTfMATEp O NTITY OF 3. WAS NK FILLED WITH A SUBSTANC AINING IN IN J{ATERIAL? ❑YES ❑ NO "i GALLONS fir.j THIS FOR HAS BEEN COMPLETTED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW EDGE, I'S TRUE AND CORRECT. APPLICANTS NAME(PRINTED$SfGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# D 0 � o0 0 y CURRE T LOCAL AGENCY FACILITY ID# APP YE Y NAME 4 AM PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER I EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: g(6-29-88) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C NT FORMA' HAS BEEN FILED DATA PROCESSING COPY