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STATE OF CALIFORN11a WATER RESOURCES CONTRARD ARD <br /> FORMV:: UNDE ROUND STORAGE TANK PROGRAM A <br /> TALK TANK PERMIT APPLICATION INFORMATION y ° <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ "N ERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> co a <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: , FARM TANK-YES O NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPO. FY <br /> A. OWNERS TANK ID a B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ✓C' U <br /> II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A 1 MOTOR VEHICLE FUEL F_� 2 PETROLEUM ��l <br /> , C. 1:11 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 0 5 HAZARDOUS 86 EMPTY [:] 95 UNKNOWN Ej 2 WASTE El 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&CAS.# C.A.S.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF i EWALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SIN WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER <br /> .TANK 1 STEEL/IRON El 2 STAINLESS STEEL 3 FIBERGLASS [:]4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B MATERIAL ❑5 CONCRETE 6 POLYVINYL CHLORIDE Q 7 ALUMINUM E]8 100%METHANOL COMPATI8LF FRP <br /> 0 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN Ej 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED 2 AL INING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LIFTING �5 GLASS LINING UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES [:] NO 99 OTHER <br /> D.CORROSION 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VI RAP Q 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION E]91 NONE 5 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE: A IFABOVE GROUND, LI IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NENTW 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEELARON 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 WJFRP A U 6 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 9 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 /> NJ. P S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P <br /> PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTWATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> f1 SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:) NO <br /> �{• GALLONS <br /> THIS FORM HAS BEA COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> Ll I I 1 1 lol(- <br /> ,�I / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BYNAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATEP MIT EXPIRATI DATE <br /> 1 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# <br /> BY: <br /> FOAM B(6-29-88) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RRENT FORM`A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />