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STATE OF-CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> FORMV: <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. <br /> f-r ,,CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> KIS <br /> ❑3 RENEWAL PERMIT ❑8 TANK REMOVED <br /> MARK ONLY ❑4 AMENDED PERMIT ❑� 6 TEMPORARY TANK GLOSURE <br /> ONE ITEMIT <br /> n (FARM TANK-YES❑ ND $� <br /> FACILITY/SITE NAMEPI8TALLED: �{� l� V[?� I <br /> I C7? <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN--SO SPECIFY (,n ` <br /> 2 B. MANUFACTURED BY: U <br /> A. OWNERS TANK ID 0 I <br /> 4�1 G7 D. TANK CAPACITY IN GALLONS: <br /> C.YEAR INSTALLED 1 � I <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARC. K,COMPLETE ITED EM D•LADED DIESEL <br /> { B. <br /> q. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM f ❑4 GASA1i0L ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> KI 1 PRODUCT. <br /> ❑3 CHEMICAL.PRODUCT ❑4 OIL 1 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> ❑5 HAZARDOUS <br /> ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE I ❑ <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF Y / C.A.S.W <br /> I HAZARDOUS SUBSTANCE STOREiD 8 C.A.S.0 �[ <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.0,C.10 <br /> ❑ <br /> ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN <br /> A.TYPE OF t DOUBLE WALLED <br /> E]99 OTHER <br /> SYSTEM F-14 SECONDARY CONTAINMENT 2 SINGLE WALLED ❑ .> <br /> ❑1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM; ❑B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE El to GALVANIZED STEEL UNKNOWN E]99 OTHER <br /> ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING <br /> C. INTERIOR ❑fi UNLINED F ❑95 UNKNOWN <br /> LINING ❑5 GLASS LINING - <br /> ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER " <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT F-13 VINYL WRAP' <br /> ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:]5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN E]99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 <br /> A SYSTEM TYPE A U 1 SUCTION A OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A u x DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A UNKNOWN A U 99 OTHER <br /> A U I STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U B 11GB0%RMETHANOL COMPATIBLNE <br /> E IRP <br /> C .MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/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 $ VISUAL CHECK �$ 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8S 9 GROUND WATER MONITORING WELLS <br /> g PRECESION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P. <br /> V . INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/Y ) 2.ESTIMATED OUAN'�ITY OF, INERT MATERIAL? []YES ❑ NO <br /> lift,/J/ SUBSTANCE REMAINING IN Q►,LLONS <br /> TFflS FORM NAS BEEN C�MPLETED UNDER PENALTY OF PERJURY,ANA TO THE BEST OF MY KNOWLEDGE,IS TRUE AfYp CORRFC7. <br /> w,w DATE <br /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) <br /> E� <br /> LOCAL AGENCY USE ONLY <br /> ECHECKI <br /> TY N JURISDICTION N AGENCY N <br /> FACILITY ID N TANK ID# <br /> L.i T 71 <br /> CAL AGENCY FACILITY ID>tAPPROVED BY NAIA PHONE N WITH AREA CODEBERPERMIT APPROVAL DATE PER IT XPIRATION AAT pERYIt AMOUNT SURCHARGEAMT. FEE CODE `'ECEIPT M BY: <br /> _ <br /> FORM `A',UNLESS A+rRENT FORM`A' HAS BEEN FILED <br /> _. <br /> fva!�g try 2s-60j�TLjt FORA!UUST BE ACCOMPAN1Eb�!A FAClL1TY1SITE PLICATION, - ^ R n �� T � <br />