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STATE OF CALIFORPTtA WATER RESOURCES CONTROL BOARD FORM '8': 7 UNDERGROUND STORAGE TANK PROGRAM '' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEWPERMIT ❑J RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/BITE NAME WHERE TANK IB INSTALLED: --p j i7G/'cr S><i'i c FARM TANK-YES❑ NO ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A OWNERS TANK ID I B. MANUFACTURED BY: (A C.YEAR INSTALLED `{CL D. TANK CAPACITY IN GALLONS: i✓� 11. TANK qONTENTS If(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),ISN MARKED,COMPLETE ITEM D. A I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. I UNLEADED ❑ 2 LEADED ❑ J DIESEL ❑J CMEMICAI.PRODUCT ❑6 O0. 1 PRODUCT ❑6 OASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D.BELOM D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.I C.A.S.I: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.f D A TYPE OF ❑ i 09LW WALLED ❑2 SINGLE WALLED VAIN EXUROR LINER ❑96 UN cwN SYSTEM SIH(EEWAUn ❑ 1 SECONAMD'CONTM MENT ❑ 99 OTHER I SfEfl.16ON ❑I STAINLESS STEEL ❑2 FIBERGLASS ❑ I SRO CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ S CONCRETE ❑6 POLYVNYLCHLORIOE ❑ 1 ALUMINUM ❑I ILYRL METHANOL COMPATI&E FRP MATERIAL ❑9 BRONZE ❑ IB GALVANIZED STEEL ❑ 95 UNCNOltt9 ❑99 OTHER G INTERIOR ❑ I RISER LINED ❑�'°/2AlK�lWING ❑J EPDXY LINING E) PHENOUCUNNG LINING ❑5 GLASSUNtNG LJU�,,L ❑95 Uwmm ❑BUNINGWTERALORAPATIBLEWITHIMAMETWa7 [-]YES ❑NO 09 ODER D.CORROSION ❑ I POLYETHEAWRAP ❑2 TAR OA ASPHALT ❑7 VINYL WRAP ❑ I RBEWAASS REINFORCED FUSTIC PROTECTION ❑S CATHODIC PROTECTGN ❑.Bf NONE ❑95 UNKNOWN ❑ 99 DIM IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE 1 SUCTI A U 2 PRESSURE A U ]GRAVITY A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U ]LINED TRENCH U 95 UNKNOWN A U 99 OTHER A U I STEELARON A U 2 STAINLESSSIEEL A U ] POLYVINYLCHLORIOE(PVCI A U A FISEROLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 5 CONCRETE A U 7 STEEL CUD W/FRP A U I ICON METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P t IVISUALCHECK P t 2 INVENTORY RECONCILIATION ► ! ]VADOSE WELLS P t A ELECTRONIC MONITOR P ■ 5 GROUND WATER MONITORING WELLS t PRECISION TESTING • 11 7 PRESSURE TESIING t 91 NOiIF" • t 95 UNKNOWN ► t MOTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 1 WAS TANK FILED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(POINTED L SIGNAT URE) DATE LOCAL AGENCY USE ONLY COUNTY P JURISDICTION I AGENCY I FACILITY ID I TANK ID 3 f�I�T1I o I o y a G I c-, I / L CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME PHONE F WITH AREA CODE 0 PERMIT NUMBER . PERMITAPPROVAL DATE PERMIT EXPIRATION DATE CHECK/ PERMIT AMO LINT ' JRCHARQE AMT. FEECODE CEIPTI BT:�.