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STATE OF CALIFORNIJ% WATER RESOURCES CONTRO ARD I: FORM V: UNDERGROUND STORAGE TANK PROGRAM T I TANK PERMIT APPLICATION INFORMATION �0 TAN COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. °•�,Fa P MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT [P"5"CHANGE OF INFORMATION ❑7 PERMANENTLY CL K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO ' I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1 Q A. OWNERS TANK ID# B. MANUFACTURED BY: P C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I � II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. co A. Vl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 4"713 DIESEL '. E ❑ 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS f ❑ 5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) F D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: p !' x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D l A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN j SYSTEM Kr2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-] 1 STEELIIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-]5 CONCRETE El6 POLYVINYLCHLORIDE r-]7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ff95 UNKNOWN ❑99 OTHER r ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR f # LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ! !I ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER L i' 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ ❑ ❑ ❑ PROTECTION ❑5 CATHODIC 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AU 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. I--- P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE T USED(MO/YR) 2. ESTIMAT QUANTITY OF 3.WAS TA K FILLED WITH SUB T S,REMAINING IN GALLONS INE T ERIAL? [:]YES ❑ NO THIS FORM H S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# D I o lo I l 1,q 16, � I I A o 0 CURRENT LOCAL AGENCY FACILITY ID# APP V D B NA E PHONE#WITH AREA CODE f j, PERMIT NUMBER PERMIT APPROVAL DAirE PERMIT EXPIRATION DATE I CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODERECEIPT# BY: 1 FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FOR M `A%UNLESS A ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY