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STATE OF CALIFORN14S 'WATER RESOURCES CONTR ARD FORM '8': UNDERGROUND STORAGE TANK PROGRgI1A TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE'FOe ! ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ! w r FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS—IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# 8. MANUFACTURED BY: —E 4bk CAS C. YEAR INSTALLED f D. TANK CAPACITY IN G ONS: 0 42,00 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 ETI PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# /�' A C.A.S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL [:]3 FIBERGLASS []4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F] 5 CONCRETE MATERIAL ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ©8 IN%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING E:] 3 EPDXY LINING ❑ 4 PHENOLIC LNING LINING ❑5 GLASS LININGUNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1 X%METHANOL? �VES ❑ NO ft OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAA OR ASPHALT ❑ 3 VINYL WARP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED U DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRP A(98 100%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. r� P S 1 VISUAL CHFCK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELL. S 4 ELECTRONIC MONITOR P S 5 GROUNDWAT=VONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF J. W 5 TANK FILLED WITH UB. NCE REMAINING W GALLONS RT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KN WLEDGE' IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [E] L= L= loloill z) 0 CURRyiTLOCAL AGENCY FACILITY IDN - F APPY NAM ' / PHONE k WITH AREA CODE 1 PERMIT NUMBER PERMIT APPROVAL DATE P MIT XPIRA ION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODS RECEIPT# BY: I` FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A(CURRENT FORMA' NAS BEEN FILED DATA PROCESSING COPY I