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STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD sy 2 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM 8 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE REM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE �' 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLE ' VVV 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWV A. OWNERS TANK I.D.A B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) 0AAAM al AZ D. TANK CAPACITY IN GALLONS: 6 ILTANKCONTENTS IFA-11S MARXED.COMPLETE ITEM C. REA A VOL1 MOTOR VEHICLE FUEL ❑ 4 OIL B. Q � L UNLEAGULDEDR 3 DIESEL ❑ • AVUTK)N GAS F-1 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT O 19 PREMIUM 4 GASAHOL E] 7 METHANOL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADEDD 99 JET99❑ (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8.AND C,AND ALL THAT APPLES IN BOX D AND A. TYPE OF InA 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 05 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ N OTHER B. TANK 1 BARE STEEL F-12 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE WIFRP (PdmeryTWt) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOP 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E&95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTON EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AD 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A4V 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 05 UNKNOWN A U W OTHER C. MATERIAL AND A&), SAFE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ M9R0RING ❑20 OTHER V.TANK LEAK DETECTION ❑ i VISUAL CHECK ® 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 05 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED GATE LAST USED AYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO E:]/—Gr� SUBSTANCE REMAINING � GALLONS INERT MATERIAL 7 ❑ THIS FORM HAS BEEN COMPLE ED NDER PENAL Z OF PERJURY,AND T THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE/ (PRINTED4 SX:NATURET //// l<.(`Ir7�/ •/ �/IIQ ' ZZ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# ry STATE LD.# m p PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. / FILE THIS FORM WITH' LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST GE TANK REGULATIONS FORM B (12.91) \ V LO-,vo 4,t�� 1-31- 0'0 r�TJL/�7 `i VV