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STATIE OF CALPFORNO- WATER RESOURCES CONTRC_IOARD ��`':' '•� FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION 7AN K COM PLETE A SEPARATE FORM WITH THE FOLLOWING INFORM7ATION FOR EACH TANK. `°-"�°'� Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMITS ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑`2.INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED D w FACILITY/SITE NAME WHERE TANK IS INSTALLED: b� FARM TANK-YES❑ NO W 00 1. TANK DESCRIPTION f COMPLETE ALL ITEMS-'IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID q O B. MANUFACTURED BY: ll� C.YEAR INSTALLED 0 K-- w„ D. TANK CAPACITY IN GALLONS: I1. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 6-1-`PRODUCT C. ❑ 1 UNLEADED LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS I ❑ 5 HAZARDOUS. ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) I D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEMSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CIAD W/FlBEAGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL oniER 10 GALVANIZED STEEL 95 UNKNOWN ❑ 9 BRONZE ❑ ❑ ❑99 ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOUGUNING C. INTERIOR LINING ❑5 GLASS LINING ED ❑95 UNKNOWN I ❑ IS LINING MATERIAL COMPAT18LE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTIONONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLI BLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A affi NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A1 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE UE C.MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER -VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE s 1. ESTIMATED DATE LAST USED(MO/YR) _ 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# El / aI lo CURRE OCAL AGENCY FACILITY IDN APPR NAME PHONE N WITH AREA CODE �L � 2 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT ExpinknoN bATE -F CHECK# PERk11T AMOUNT SURCHARGE AMT. FEE CODE ` RECEIPT N BY: I � 1 FORM B(6-29-88) THIS FORD DUST BE ACCONP BY A FACILITY/SITE APPLICATION, FORM `A',UNLE CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY":_,