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STATEOFCAUFORMA .r -.,,„ ® STATE WATER RESOURCES CONTROL BOARD i� ,mom UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 8 ;y j COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 9 TEMPORARY TANK CLOSURE ❑ 9 TANK REMOVED 0 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.a 0 -.5-- B. MANUFACTURED BY: C- C. DATE INSTALLED(M6'DAYNEAR) LA tL" D. TANK CAPACITY IN GALLONS: U O II.TANK CONTENTS IF A.I IS MARKED.COMPLETE ITEM C. A, ❑ 1 MO R VEHICLE FUEL ❑ A OIL g, C ❑ IaUREGULAR e 7 DIESEL ❑ 9 AVIATIONGAS TROLEUM PWIEMPTY 1 PRODUCT ❑ 1eUNLEMAOED A JET FUEL ❑ 7 METHANOL ❑ ❑ 7 S CHEMICAL PRODUCT r�r:ida5 UNIOJOWN ❑ 2 WASTE ❑ 2 LEADED W OTHER (DESCRIBE IN ITEM 0. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED €��, /t tit G V C.A S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANO C.AND ALL THAT APPLIES IN SOX O AND A. TYPE OF DOUBLE WALL WALL ❑ [:]S SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK I❑ III BARE STEEL ❑ 2 STAINLESS STEEL 0 FIBERGLASS ❑ a STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL U 5 CONCRETE ❑ 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN N OTHER ❑ 1 RUBBER LINED ❑ 2 KYO LINING ❑ 7 EPDXY LNING A PHENOLIC LINING C.INTERIOR 5 Guns LINING 8 UNLINED LINING ❑ as UNKNO 90 OTHER IS UNNG MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES— D. ES_D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 0 VINYL WRAP ❑ A FIBERGLASS REINFORCEDFUSTIC PROTECTION ❑ S CATHODIC PROTECTION ✓ 91 NONE ❑ 95 UNKNOWN [::] 99 OTHER E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND,BOTH IFAPPLICABI.E A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A UA UA C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC)A ♦ FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WICOATINO A U B 100% METHANOL COMPATIBLE WZFRP PROTECTION A U 9 GALVANDEO STEEL A U 10 CATNODIC PROTECTION A U 95 UNKNOWN A U 90 OTS— D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 UNE TgHTNESS TESTING ❑ MONROR9Ki ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3Z MONITORING ❑ l AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING !❑ 0 TANK TESTING ❑ 7 INTERSTITIALMONITORING 91 NONE ❑ 95 UNKNOWN ❑ W OTHER VI.TANK CLOSURE INFORMATION t.ESTIMATED DATE LAST USED(MO/OAY/YR) 2 ESTIMATED QUANTITY OF S.WAS TANK FILLED WITH ✓ ti-�n...Y, r7 f� SUB STA NCEREMAINING LJ 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 (MK a5 MTI41MI DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION f FACILITY s TANK k D wyV 1 STATE LDAFTW� I= d 7= E=II7Fo L7Y PERMIT NUMBER PERMITAPPROVED BY/DATE PERMIT EXPIRATIONQATE �3 (,J FORM B (791) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. f FORM"