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17y" 7. 17 vw�, <br /> STATE OF CALIFORNifa WATER RESOURCES CONTROSOARD <br /> FORM V: UNDERbROUND STORAGE TANK PRO AM ; <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. _ <br /> MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSE K <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT F1 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED d <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: tv, (�(c_. 1 FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# v B. MANUFACTURED BY: jjyt 5 <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS ❑ 80 EMPTY [-] 95 UNKNOWN 2 WASTE ❑ 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> III. TANK CONSTRUC ION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ UBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 214; LE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESSSTEEL F-]3 FIBERGLASS 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL F-15 CONCRETE 6 POLYVINYLCHLORIDE F-] 1 ALUMINUM F-] 8 100%METHANOL COMPATIBLE FRP <br /> E]9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN [::]99 OTHER <br /> 1 RUBBER LINED 2 KYD LINING 3 EPDXY LINING F__]4 PHENOLIC LINING <br /> C. INTERIOR <br /> LIM <br /> LINING 5 GLASS LINING LINING MATERIAL COMPATIBLE WIT UN00%METHANOL? El YES D NO LINED ❑ 99 OTHER <br /> Sf/s <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT F-] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE [:]95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF AB VE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> 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 <br /> B. CONSTRUCTION A 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE 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 /> ph <br /> P 1 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 6 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 OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [:] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> E <br /> JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> [all I 0E[ I Cha l ., oeO v 7 <br /> AGELAITY ID# J APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY: A <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM`A',UNLA CESS RRENT FORMA' HAS BEEN FILED/'`�/ <br /> DATA PROCESSING COPY <br />