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STATE OF CALIFORNIA WATER RESOURCES CONTROL 9*D FORM V: UNDERGROUND STORAGE TANK PROGRAM Qp TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC"TANK MARK ONLY ❑ I NEW PERMIT p 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSEDTANK ONE ITEM ❑2 INTERIM PERMIT E] NK E AMENDED PERMIT p 6 TEMPORARY TACLOSURE pNK 6 TAREMOVED l.T FACILT'/SM NAME WHERE TANK IS INSTALLED: - FRAM TANK-YES❑ NO L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—BO SPECIFY A. OWNERS TANK 10 E QQ B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(AIN IS MARKED,COMPLETE ITEM C.IF(A.1),18 NOT MARKED,COMPLETE ITEM D. A. ❑1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. C.1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL ❑1 PRODUCT ❑A GASAHOL ❑5 FUEL p 6 AVIATION GAS ❑5 KQARDOUS p 80 EMPTY p 95 UNKNOWN ❑2 WASTE ❑7 METHANOL OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CA.S.9 L CAS,E: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A.E.C.A D A TYPE OF © 1 WIALEWAUED ❑3 SINGLEWAUEDWI1HEXTERORLEER S5 mm" SYSTEM p 2 SINGLE WAILED p A SECONDiM'CONTANMEM ❑M OTHER p 1 mum" ❑2 STNMESSSTM ❑3 FIBERGLASS ❑A SIM CA W/RBERGULSS REWORDED PLASTIC E.TANK p 5 CDND p 6 POLVANYL CHLORIDE p 7 ALUMIMIM p I IoW LIETIVWOL CDWATBLE PAP MATERML p 9 BRONZE ❑ 10 GALVANIZED STEEL p%IAE(NONTI p N OTHER p I RIBBER LINED p 2 A-M UNING p 3 EPDXY LINING p A PHENOLIC LNING G INTERIOR 5 GLASS LINING ❑6 MEWED ❑95 UNKNOWN LINING ❑ p*LNW.WATEPi*ICDMPATPBLEWrTHIOD%WDW*OLI p YES p NO p 99 Ono D.CORROSION ❑1 POLYETME7E WRAP p 2 TNI OR AULT p 3 VINYLWRAP ©A RBERGtASSREINFORCEIPWS IC PROTECTION p 5 CATHODIC PROTECTION p 91 SRNONE ❑95 UNMOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A V,2 PRESSURE A U 3 GRAVITY A U 91 NONE A U M UNKNOWN A U "OTHER E CONSTRUCTION A U 1 SINGLE WALLED A i U''2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U %UNKNOWN A U "OTHER A U ISTEECARON A U 2STAMLESSSTEEL A U 3 POLWINYL CHLORIDE(PVC) A C E FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U N OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. � • � t VISUAL C$CHECK P 2 INVENTORY RECONCILIATION P • 3 VADOSE WELLS • A ELECTRONIC MONITOR P • 5 GROUND WATER MONITORING WELLS • 6 PRECISION TESTING P E 7 PRESSURE TESTING P S 91 NONE P S N UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE UST USED(MO/YR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN G Loks INERT MATERIAL' ❑YES p NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A ;FO H ST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE F.J. MFYFR-U.G.T.ANALYST r3 Q LOCAL AGENCY USE ONLY COUNTY 9 JURISDICTION E AGENCY• ACILITY IDE TTANKID09CUR ENNTTLOCALAGENCY FACnm ID 9 APPROVED•YNAPE PR G C Pd1Yrt BUMPER PERMIT APPIIOVAL OATS PERMIT EEPMATN)N DATE CHECK• PERYR AMOUNT WRCHAAGE AMT. PEE COOS RECEIPT 9 •Y: , I� n FORM R(62926) THIS FORM MUST M ICCOIMANMD BY A FACERYRIRE APPLICATION, FORM 'A',UK M A COMM FOW'A' IMS SEEN FRED Z DATA PRL ;SING COPY 2 LOCAL.AGENCY COPT MILE COPY I�l