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STATE OF CALIFORNIAWATER RESOURCES CONTROL BOARD <br /> FORM V: UNDE10ROUNDSTORAGE TANK PRO*AM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF MATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT ®3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ®7 PERMANENTLY Cl <br /> M, <br /> ONE ITEM ®2 INTERIM PERMIT ❑4 AMENDED PERMIT �6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO <br /> 1. TANK-DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I A <br /> A. OWNERS TANK 10# S. MANUFACTURED BY: U <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS:a Z2 <br /> 11. TANK CO ENTS IF(A.1),IS MARKED,compLETa ITEM C.IF(A.1),IS NOT MARKED,C,?METE ITEM D. <br /> A. MOTOR VEHICLE FUEL ®2 PETROLEUM B. C. UNLEADED ®2 LEADED ®3 DIESEL m <br /> ®3 CHEMICAL PRODUCT , ❑ 4 OIL 1 ppOpUCT ❑4 GASAHOL ® 5 JET FUEL 6 AVIATION GAS <br /> ®5 HAZARDOUS 'a 80 EMPTY ®95 UNKNOWN ®2 WASTE ® 7 METHANOL ®99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# A119— C.A.S.W <br /> x1II. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D <br /> A.TYPE OF ❑ iWAUB ❑3 SNGI E WALLED WITH LINER &5 UNKNOWN <br /> SYSTEM WMiED ®a CONTANIENT 99 OTHER <br /> STEWIRON ®2 STAINLESS STEEL ®3 RBEIMASS ®4 STIR CLAD W/RBEMASS REINFORCED PLASTIC <br /> B.T ❑5 awmm ®8 POLYVIWL0lLORIDE ®7 91RANUM ❑8 10096 METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ®9 BRONZE 10 Cu1LVANIZEDSTEEL ®96 UNKNOWN ®99 OTHER <br /> C.INTERIOR ®i ROM LINED ®2 ALKYD UNING ®3 EPW UNN ®4 C UNING <br /> LIMING ❑5 GLASSUNING ®95 UNKNOWN <br /> ®IS LINN MATERIAL COMPAME WITH ION ? ❑YES ®NO ®99 OTHER <br /> 0.CORROSION ❑ 1 POLYETHLDIE WRAP ®2 TAR OR ASPHALT ®3 W&WRAP ®4 RBERGAM REIWORM PLASTIC <br /> PROTlEalON ®5 CATNODICPR07ECTION g4M61E 95 UNKNOWN ®99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A Sysm Tm A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONMUCTM A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 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 <br /> C.MATERIAL A U S ALUMINUMJ A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 ANIZED STEEL A 05 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 /> t��loll p i VISUAL CHECK &S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 8 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE' P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF3.WAS TANK EILLED WITH <br /> ` GALLONS <br /> REMAINING IN INERT MATERIAL? r-1YES ❑NO <br /> ®t/ <br /> THIS FORM HAS JkEN 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 lim <br /> COUNTY# JURISDICTION# AGENCY# FACILITY 10# TANK 10# <br /> 3 3 <br /> CURRENT LOCAL AGENCY FACILITY ID OVER PHONE t Y„.., <br /> PERMIT NUMBER PERMIT OPAL 0A RMCT EXPIRATION DATE <br /> Z- <br /> CK a PERMIT N1t SURCHARGE CooE RECEIPT <br /> FOR a(3-749) THIS ft)RM A A FA TSN, FORM`A', FORMA' S <br /> DATA PROCE ING COPY - �” �� <br />