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FNIA STATE WATERSTATE RESOURCES OCONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FU4_ ORM B COMPLETE A SEPARATE FO MARK ONLY Nom„ P RM FOR EACH TANK SYSTEM.ONEITEM ❑ ERMIr❑ 2 INTERIM PEgMIT � 3 RENEWAL PEgMIi ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION DBA OR FACILITY NAME WHERE TAN ❑ 6 TEMPORARY TANK CLOSURE O T PERMANENTLY CLOSED ONSITE K IS INSTALLED: LD8 TANK REMOVED I. TANK DESCRIPTION ZOO/D GGF/�E COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.s /, v' C. DATE INSTALLED(MO/DAY/YEAR) - B. MgNUFgCTURED BY: ' D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A, �'1 MOTOR VEHICLE FUEL ❑ 4 OIL B BO EMPTY ' UNLEA ED ❑ 6 AVIATION GAS REGULAR E] 2 PETROLEUM ❑ C• ❑❑ 3 DIESEL 1 PRODUCT 5 JET FU+ELL ED 3 CHEMICAL PRODUCT ❑ 0.5 UNKNOWN ❑ 2 bUNLEADI WASTE 2 LEAED ❑ 7 METHANOL D. IF^I)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED � � OTHER (ESCRIBE IN ITEM D. BELOW) c.as.,r: III. TANK CONSTRUCTION MARKONE ITEMONLY IN BOXES A,B,AND C,AND AIL THAT APPLIES IN BOXD ANDE A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINEA _ 95 UNKNOWN SYSTEM El SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 1001 METHANOL COMPATIBLE W/FRP (PdM&rYTalk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL -�95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR F—] 5 GLASS LINING ❑ 6 UNLINED e95 UNKNOWN 99 OTHER LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 V YL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-1 5 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 AIFABOVE GROUND ORUIFUNDERGROUND,BOTHIFAPPLICABLE A. SYSTEM TYPE A®1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U S9 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 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 1009: METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION t f5mUNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING NG TIAL ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING 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 DATE (PRINTED 8 SIGNATURE( LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# F TANK# STATE I.D.# PERMITNUMBEP IPERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE r/` Z4 f FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UN SS A CURRENT FORM A HAS BEEN FILED. FORINISI 5 Y I a. .J