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STATE OF CALIFORNIA ` DERSTATE WATER RESOURCES CONTROL BOARD - . _ o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 8 `mom IVB. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON T ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: f Oe•vv\o1 U IIS O el I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK L D.# 39- 505099-01 B. MANUFACTURED BY: V L.VI OL..3 V*\ C. DATE INSTALLED(MO/OAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLEADED H 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY I PRODUCT REMPLIM❑❑ 1<MIOMRAOEUNLEADEED 5 D 4 GASAHJET UEL ❑OL 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ® 2 LEADED C9 99 OTHER(DESCRIBE N TEAT O.BELOM D. IF(AI)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKCWN SYSTEM w 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD UNING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC UNING LINING OR a 5 GLASS UNING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO-j D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ® 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,ILC. SPILL CONTAINMENT INSTALLED(YEAR) 14 A OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRECH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE 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 COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 �LIE OF ❑2 URL narrtRLsa 3 caxr#AIOIs wrDsnnu ❑4 BEGIRCMC uxE ❑5 Aff u rlc MwEg 99 DIRER UAV.'NDWtn o Crm Ms IGONraRa#I tLAR oLTEcraR sRuroowx V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECINVENTORY L] 3 B ❑ 4 G"" C TANK ❑5 WATERANNUAL RECONCILIATION MO ORING GAGMONITORING TESTINGTANK ❑ 7 MON TOR U INTERSTITIAL ❑ 8 SIR ❑ 9 TSF GA�NGAL [:110 MEONTHLY TANK ® 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATEDQUANTITY OF 1 WAS TANK FILLED WITH YES NO r.. ICTC�p SUBSTAGE REMAINING 0 GALLONS INERT MATERIAL7 ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME /� /� DATE (PRIMED 8 SIGNATURE) E O K r{L S-Tm fj S1319(. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBEAS BELOW COUNTY# JURISDICTION# FACILITY# TANK#dgq=W �X STATE I04 1,57f U I(o I PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE SII" THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR WSTAL3A S.THI-SIFORM FORM B (6-95)SHOULDBE ACCOMPANIED BY A PLOT P_E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF GROUND STORAGE TAANNKREGULATIONS F -