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a ` � • gSaUw Fg <br /> P 4 <br /> STATE OF CALIFORNIA o <br /> STATE WATER RESOURCES CONTROL BOARD .� . <br /> UNDERGROUNDSTORAGE TANK PERMIT APPLICATION - FORM 8 raf o <br /> °�a iron N+r <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT �' S CHANGE R INFORMATION <br /> 0 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM 2 INTERIM PERMIT <br /> a 4 AMENDED PERMIT � 6 TEMPORARY TANK CLOSURE � B TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: t')� 1)O( (N NSI <br /> I. TANK'DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN B MANUFACTURED BY: <br /> A. OWNER'S TANK I-D.N <br /> X F t]Dii D. TANK CAPACITY IN GALLONS: <br /> C. DATE INSTALLED(MO/DAY/YEAR) L 1 I J <br /> II.TANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C. 1a REGULAR 3 DIESEL 6 AVIATIONGAS <br /> A 1 MOTOR VEHICLE FUEL LF74 B. C' UNLEADED 4 GASAHOL1b PREM}L1M 7 METHANOL2 PETROLEUM MPTY 1 PRODUCT Q UNLEADED 1�15 JET FUEL <br /> 3 CHEMICAL PROOUGTNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED <br /> 111, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E <br /> 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> A. TYPE OF 99 OTHER <br /> SYSTEM 2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANK) <br /> a 1 BARE STEEL � 2 STAINLESS STEEL � 3 FIBERGLASS � 4 STEEL GLAD W!FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 10096 METHANOL COMPATIBLE W 1 RP <br /> MATERIAL s CONCRETE <br /> (Primary Tank) � 9 BRONZE � 10 GALVANIZED STEEL � 95 UNKNOWN � 99 OTHER <br /> 1 RUBBER LINED 0 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR I4 5 GLASS LINING � 6 UNLINED 95 UNKNOWN 99 OTHER <br /> LINING vele <br /> IS LINING MATERIAL COMPATIBLE WITH 10091, METHANOL? YES_ NO� <br /> 0 1 POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP Our 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION 91 NONE Q 95 UNKNOWN 99 OTHER <br /> PROTECTION 5 CATHODIC PROTECTION <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) Q OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IVFAPIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> TYPE A U 1 SUCTION A U <br /> PRESSURE A U 3 GRAVITY A U O7WNA <br /> RUGTVON A U i SINGLE WALL A U UBLE WALL A U 3 LINED TRENCH A U 95 U9 OTHERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A UOSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING APOMPATIBLEWIFRPCTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING <br /> 9 MDNRORING D 99 OTHER <br /> V.TANK LEAK DETECTION <br /> � IATtON � 3 VADOZE MONITORING �4 AUTOMATIC TANK GAUGING C 5 GROUND WATER MONITORING <br /> 1 VISUAL CHECK 2 INVENTORY RECONGIL <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING 91 NOME 95 UNKNOWN 99 OTHER <br /> VI.TANK CLOSURE INFORMATION 3,WAS TANK FILLED WITH YES NO ,I <br /> 1.ESTIMATED DA E LAST USED(MOIDAYNR) 2.ESTIMATEDSUBSTANCE <br /> REMAINING <br /> OF GALLONS INERT MATERIAL? L <br /> SUBSTANCE REMAINING <br /> THlS FO HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TR�7UE ANDCCORRECT <br /> APPLICANTS NAME n Ifr7 17, <br /> }PRINT 1G ATV ' <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK <br /> COUNTY# JURISDICTION# FACILITY# <br /> STATE I.D.# W rin= - ---- <br /> PERMIT NUMBER <br /> —� PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORo0340-Re <br /> FOAM B (12-91) <br />