Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
STATE OF CALIFORNIP WATER RESOURCESCONTROARD �,`"', <br /> FORM V: UNDERGROUND STORAGE TANK PR RAM L <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. <br /> MARK ONLY F-] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED , <br /> ONE ITEM 2INTERIM PERMIT El 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE STANK REMOVED / <br /> RM TANK-YES❑ NO <br /> FACILITY/SITE NAME WHERE TANK IS STALLED: <br /> IN .�1 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> N <br /> A. OWNERS TANK ID B. MANUFACTURED BY'. <br /> C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Da <br /> II. TANK 22NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,qMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B UNLEADED 2 LEADED 3 DIESEL <br /> C. 1 <br /> � 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 3 CHEMICAL PRODUCT F-] 4 OIL �t PRODUCT <br /> El 5 HAZARDOUS El 80 EMPTY ❑ 95 UNKNOWN El 2 WASTE 0 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CA S. <br /> q. <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1�f WBLE WALLED � 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLEWALLED F� 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON F-�2 STAINLESS STEEL F-] 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE F� 6 POLYVINYLCHLORIDEEl,,�ALUMINUM 8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE F-1 10 GALVANIZED STEEL 21 95 UNKNOWN 99 OTHER <br /> El 1 RUBBER LINED F-1 2 ALKYD LINING 3 EPDXY LINING n 49RENOLIC LINING <br /> C. INTERIOR F-] 5 GLASSUNING ❑6 UNLINED � 9595 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' YES D NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENEWRAP F-12 TARORASPHALT F 3 WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F] 5 CATHODIC PROTECTION E] 91 NONE 5 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A 1 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 1 SINGLEWALLED 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 1 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 U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL !i95 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 5 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 <br /> 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 5 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 OUANTITY OF ANN FILLED WITH <br /> 3. WAS T <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [:] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 0 D � 3 s � CSU <br /> CURRENT LOCAL AGENCY FACILITY ID k , I I I <br /> APPROVED BY AME PHONE#WITH AREA CODE <br /> PERMIT NUMBER U N V PERMIT APPROVAL DATE ry PERMIT EXPIRATION DATE <br /> L A <br /> CHECKM PERMIT AMOUNT SURCHARGEAIAT. FEE CODE ECEIPT# BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />