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STATE OF CALIFORNIA O WATER RESOURCES CONTROOARD <br /> FORM V: UNDE ROUND STORAGE TANK PRRAM ` <br /> TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> TANK Z <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OFINFORMATION 7 PERMANENTLY CLOSEDTANK , <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED N <br /> FARM TANK-YES❑ NO .A <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: , �! <br /> I. TANKDESCRIPTION COMPLETE ALLITEMS-IFUNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# 10 <br /> B. MANUFACTURE�GALLONS� <br /> CYEARINSTALLED C.e KD. TANK CAPACIT �00 �� <br /> II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL � 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT �4 OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 0 6 AVIATION GAS <br /> 0 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN 2 WASTE 0 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# IV 14 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,,C,S D <br /> A TYPE OF ❑ 1 7UBLEWALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLEWALLED F_�4 SECONDARY CONTAINMENT 99 OTHER <br /> EP'<mELIIRON F-1 2 STAINLESS STEEL F_�3 FIBERGLASS 0 4 STEEL CLAD W/RBERGLASS REINFORCED PLAST'C <br /> 8.TANK F-1 5 CONCRETE 6 POLYVINYLCHLORIDE F-1 7 ALUMINUM 8 ICA METHANOL COMPATIBLE FRP <br /> MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> r7 1 RUBBER LINE 2 ALKYD LINING 3 EPDXY LININGn 4 P�iENOUC LINING <br /> C. INTERIOR 5 GLASS LINING fi UNLINED L^��y'(UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH IDA METHANOL? DYES ONO 099 OTHER <br /> D.CORROSION ❑ 1 POLYEIHLENEWAAP ❑2 TARORASPHALT F_�3 V WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION D 5 CATHODIC PROTECTION 91 NONE 5 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A WABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE U 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 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 <br /> AU STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U S 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 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 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS <br /> 6 P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> ESTIMATED QUANTITY Of 3.WAS TANK FILLED WITH <br /> 2. <br /> 1.ESTIMATED DATE LAST USED(MO/YR)IVA SUBSTANCE REMAINING IN INERT MATERIAL? OYES ONO <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> FoTo-Tail <br /> APPROVED BY NAME •� PHONE#WITH AREA CODE <br /> P77 <br /> FACILITY �� � nA/✓ <br /> PERMIT APPROVAL DATE ERMR EXPIRATION DATE <br /> ' (�/ SURCHARGE AMT. FEECODE RECEIPT• BY: <br /> U FORM B B-29-8B) THIS FORM MUST BE ACCOMPA D BY A FACILITY/SITE APPLICATION, FORM `A',UNLE. CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />