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STATE OF CALIFORNIA "`6�•""e �w STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 8 ms ( COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS N SITE ONE REM ❑ 2 INTERIM PERMIT F—] 4 AMENDED PERMIT E:] 6 TEMPORARY TANK CLOSURE E TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.X B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: t II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 7 MOTOR VEHICLE FUEL ❑ 4 OIL B. C, ❑ 1a REGULAR UNLEADED 3 DIESEL ED AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY Ef1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1C MIDGRADE UNLEADED E] 5 JETFUEL ❑ B MB5 ❑ 3 CHEMICAL PRODUCT E] 95 UNKNOWN 1:12 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.X: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM k 2 SINGLE WALL F-14 SINGLE WALL IN A VAULT ❑ 99 OTHER S. TANK Ck1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR 1 RUBBER LINED E]2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING ❑ LINING OR ❑ 5 GLASS LINING 8/UNUNED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— 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,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROPTUBE VES 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 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH 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 A5 ALUMINUM A U 6 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 ❑N%CaORLL LINE UeAI( 2 UNE 710! N 4 3 LOMIWWS IMERSTmAL 4 ELECTRONIC UNE O 5 ADTOMPI 11 ❑ 99 OTHER DETECTOR mn w MOMTORING Lw Dmmm SNU ffl V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 MANUAL RECONCILII TIONORY ❑ 3 MONIITORING VAOZE ❑ 4 GAUGING AUTOMATIC TANK ��❑ 55GROUND�MON TORINGTER ❑ 6 TEEMINGTANK ❑ 7 MONITORING ❑ 8 SIR ❑ 9 TANEKLY KGAUGINGAL ❑10 TESTING TANK '= _5 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED CLANTTY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES E:] NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THEBES F MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 8810NATURE�!v LOCAL AGENCY USE ONLY 14E STATE I.D.NUMBER IS COMPOSED OFTHjfllrR NUMBERS BELOW JY� COUNTY X JURISDICTION X FACILITY STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT AP{�ON•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED, C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T ERGROUND STORAGE TANK REGULATIONS FORM B (6-95)