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STATE OF CALIFOR04 WATER RESOURCES CON'•L BOARD <br /> FORM V: UNDERGROUND STORAGE TANK PROGRAM , >. <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 1 <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Ej 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT / AMENDED PERMIT 6 TEMPORARY TANK CLOSURE �y�TA�K REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> FARM TANK-YES[:] NO f <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CI <br /> C <br /> A. OWNERS TANK ID N B. MANUFACTURED BY: r <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. G ❑ I UNLEADED 0 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 1 OIL Ej I PRODUCT A GASAHOL D 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS M EMPTY D 95 UNKNOWN 2 WASTE 7 METHANOL O 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.N' <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A TYPE OF ❑ I DOUBLE WALLED D 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLEWALLED A SECONDARY CONTAINMENT 99 OTHER <br /> I STEEUIRDN 2 STAINLESS STEEL 3 FIBERGLASS 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.T ANTERUL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 6 10096 METHANOL COMPATIBLE FRP <br /> ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR ❑ I RUBBERUNED D 2 ALKYO UNING 3 EPDXY LINING A PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING 06 UNLINED 95 UNKNOWN <br /> ED IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? YES NO 99 OTHER <br /> D.CORROSION ❑ I POLYETIEENE WRAP 2TARORASPHALT 0 3VINYL WRAP 0 /FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION O 91 NONE 1:1 95 UNKNOWN D 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U I 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 U I STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U < FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FOP A U B 10096 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES D NO <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 /> COUNTY N JURISDICTION N AGENCY I FACILITY ID N TANK ID N <br /> CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY!PEOUIT <br /> ���� �["/ PHONE/WITH AREA CODE <br /> PERMIT NUMBER jf PERMIT APPROVAL DATE 1EXPIRATION CHECK I PERYIT AMOUNT SURCHARGEAMT. FEE COCEIPT I <br /> er: <br /> FORM B(6-29.BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION. FORM 'A'-DNLFSS I CIIRRFYT c1...1., «.,—... <br />