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STATE OF CALIFORNI< WATER RESOURCES CONTROI . 7ARD FORM V: UNDE95ROUND STORAGE TANK PROOAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. Z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT FLkrcANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT n 6 TEMPORARY TANK CLOSURE 8 dK REMOVED Q W FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDB B. MANUFACTURED BY: C. YEAR INSTALLED u D. TANK CAPACITY IN GALLONS: II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1 IS NOT MARKED,COMPLETE ITEMit A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.W C A.S.9 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I DOALE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ff�95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-17 ALUMINUM F-] 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 70 GALVANIZED STEEL [2f UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PFjENOLIC LINING C. INTERIOR 1^i yam' LINING ❑ 5 GLASS UNING El UNLINED 5 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 ❑YES ❑ NO �90THER � D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 V LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 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 AEJ95 UNKNOWN A U 99 OTHER 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 99 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P) 8 1 VISUAL CHECK p 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S d ELECTRONIC MONITOR p S 5 GROUND WATER MONITORING WELLS MP S 6 PRECISION TESTING p S ] PRESSURE TESTING p S 91 NONE P S 95 UNKNOWN p S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY* FACILITY ID M TANK ID S [31il = 10161 (441v GDo CURB CAL AGENCY FACILITY IDN APPROVED BY NAME L., PHONE N WITH AREA CODE t(cIt' IN-5a i yx PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 1 `I E4iCK PERMITAMOUNT SURCHARGE AMT. FEE CODE R€CEIPTN BY: �}! FORMB(6-29-w) THIS FORM MUST BE ACCOMPANIEDBYAFACIUTY/SITEAPPLICATION, FORM 'A',UNLESS A RRENT FORMA' HASBEENFILED DATA PROCESSING COPY