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STATE OF CALIFORI& WATER RESOURCES CON BOARD °•' FORM V: UN RGROUND STORAGE TANK PROGRAM `_ TANK TANK PERMIT APPLICATION INFORMATION �20� ' _ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. L NL MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED� ONE ITEM [:]2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED /V G FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO H C1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECT Y a A. OWNERS TANK IDN B. MANUFACTURED BY: n C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑< OIL ❑ 1 PRODUCT ❑ / GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑60 EMPTY ❑95 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.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B.C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STERARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑/STEEL CUD WIFIBERGUSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLWINYLCNLORIOE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C.INTERIOR I RUBBER UNED ❑2 ALKYD UNING ❑ 3 EPDXY LINING E]/PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAO OR ASPHALT ❑3 VINYL WRAP ❑ 1 FIBERGLASS REINFORCED PUSTIC PROTECTION ❑5 CATHOOIC 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 U 95 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 A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U < 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 B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 i l VISUAL CHECK P • 2 INVENTORY RECONCILIATION P • 3 VADOSE WELLS P i a ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS P { 8 PRECISION TESTING P i 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N / l U � CURRENT LOCAL AGENCY FACILITY ID /. APPROVED BY NAME P NE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E I ION DATE CHECK N PEflYIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FDNMB(Ns9.ee) THIS FORM MUST BEACCOMPANIEOBYA FACILITY/SITE APPLICATION, FORM 'A',UNLE$SACURRENT FORMA' HASBEENFILED A DATA PROCESSING COPY