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STATEOFCAUFORNA STATE WATER RESOURCES CONTRORMITI� � UNDERGROUND STORAGE TANK PE 1% COMPLETE A SEPARATE FORM FOR EACH T SYSTEM MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED / DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 16 I T C-4- 47�;-3 6 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.• B. MANUFACTURED BY: U C. DATE INSTALLED(MO/DAY/YEAR) v K O. TANK CAPACITY IN GALLONS: O O II.TANKC ENTS IFA-1 IS MARKED,COMPLETE ITEM C. A I MOTOR VEHICLE FUEL ❑ A OIL e. C. la REGULAR 3 DIESEL ❑' S AVIATIXIGAS ❑ 2 PETROLEUM 90 EMPTY 1 PRODUCT ❑ 10 PREMIUM A GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 1 2 LEADED 99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES AB.ANDC.ANDALL THAT APPLIES IN BOX A. TYPE OF WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ B. TANK 1 RARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE7 AL MINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (Pnmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ W OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LW WG ❑ 3 EPO LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED IQ/OWN ❑ 90 OTHER LINING G LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ N OTHER IV.PIPING INFORMATION CIRCLE AIFABOVEGRWNDORUIFUNDERGROUND.BOTHIFAPPLICABLE A. SYSTEM TYPE A u 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U W OTHER C. MATERIAL AND A U 1 RARE STEEL A U 2 STNNLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 9 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANREO STEEL A U 10 CATHOOICPROTECT'ON A 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 ATMS ITIA ❑ 99 OTHER MONITRING V.TANK LEAK DETECTION ��NNNi7OOOOMMMM F71 VISUAL CHECK F72 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING TIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 9 TANK TESTING [:] TTWC:]7 INIERSTLMONFTORING 91 NONE �_(.�95 UN 010WN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO/DAY/YR) I 2.ESTIMATED OUANTf)Y OF 3.WAS TANK F81EO WITH YES ❑ NO C:]SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGF- IS TRUE AND CORRECT APPLICANTS NAME DATE IPgNTa9 i LG1MNRq LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY x TANK# STATE I.D.# Nil I alQ 0 0 6 0 PERMIT NUMBER I PERMIT APPROVE08YADATE PERMIT EXPIRATION DATE FORM 8 (990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOAOIIB.IM