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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a FORM `8': UNDERGROUND STORAGE TANK PROGRAM � AL = TANK TANK PERMIT APPLICATION INFORMATION k �. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z I t_, MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED /fir '/ IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: I FARM TANK-YES❑ NO cn 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED -Z_ D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL R-7-PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL L2<WATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A0411 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 6A.1 V4 I III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM + �2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER E�i<sTEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/HEERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F—] I RUBBER LINED El2 ALKYD LINING F—] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING [J16 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ i POLYETHLENE WRAF ❑ 2 TAR OR ASPHALT ❑� 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION E] 91 NONE P95.UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFA E GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION AV 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FfBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W1 FRP A U B 100%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 1 VISUAL CHECK Re P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S PRECISION TESTIN P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK LED WITH SUBSTANCE REMAI G IN GALLOWS INERT M R L? E]YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERU RY AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY EPERMITNUMBER [�El JURISDICTION# AGENCY# FACILITY IDN TANK ID# 16, ILE] b I o I o Ll AGENCY FACILITY ID N APPRO D GY AME PHONE#WITH AREA CODE PM APP OV/1L DA P€RMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AM . FEE CODE RECEIPT# BY: FORM B(6-29-68) THIS FORM MUST BE ACCOMPMED BY A FACILITYISITE APPLICATION, FORM 'A',UNLEGn CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY