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STATE OF CALIFORWM WATER RESOURCES CON L BOARD .'.'1-4'. <br /> FORM V: UNIFERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATIONo a, <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL <br /> ONE;ITEM El 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> o FACILITY/SITE NAME WHERE TANK IS INSTALLED: t S FARM TANK-YES E:l NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SID SPECIFY <br /> A. OWNERS TANK ID N B. MANUFACTURED BY: W <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ®i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ® 1 UNLEADED ®2 LEADED E]3 DIESEL <br /> ❑3 CHEMICAL PRODUCT 4 OIL ® T PRODUCT ❑4 GASAHOL 5 JET FUEL f__�6 AVIATION GAS <br /> ®5 HAZARDOUS 80 EMPTY [:]95 UNKNOWN ®2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> O. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.M <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM 2 SINGLEWALLEO 4 SECONDARYCONTAINMENT 99 OTHER <br /> TANK I STEEUIRON 2 STAINLESS STEEL ®3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> ®.MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE ®7 ALUMINUM 8 10094 METHANOL COMPATIBLE FRP <br /> E]9 BRONZE 10 GALVANIZED STEEL ®95 UNKNOWN D 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED E]2 ALKYD LINING ®3 EPDXY LINING E:]4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING f_�6 UNLINED F�95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ®YES ®NO E]99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP r__j 2 TM OR ASPHALT ®3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION [D 91 NONE ®95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE 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 /> 8.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1STEEL/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 /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUNDWATER 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 INERT MATERIAL? ®YES ®NO <br /> OALLONS <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 /> t <br /> LOCAL AGENCY USE ONLY MEMO <br /> COUNTY M JURISDICTION N AGENCY N FACILITY ID M TANK ID S <br /> y __LE <br /> E L LLJ L _171 4/1 �T 7/ F_ I <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> wo <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> d) <br /> CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: <br /> roHM B(6•29-88) THIS FORM MUST BE ACCOMf e0 BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN LED <br /> DATA PROCESSING COPY <br />