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STATE OF CALIFORN10 WATER RESOURCES CONTR OARD FORM `8': UNDERGROUND STORAGE TANK PRRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 90 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [9'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C"LJ NK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED///J GJ FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO � R3 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY F-+ A. OWNERS TANK ID 4 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ((} II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. IJ MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL �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.N C.A.S. �# K III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ .DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM r I °SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ' STEELIIRON ❑2 STAINLESS STEEL F__] 3 FIBERGLASS F-]4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK fJ❑ MATERIAL 5 CONCRETE F-16 POLYVINYLCHLCRIDE ❑ 7 ALUMINUM E]3 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F__] 1 RUBBER LINEO E] 2 ALKYD LINING El3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASSUNING ©'6 UNLINED ❑ 95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER D.CORROSION ❑ 1 POLYEFHLENEWRAP ❑2 TAR OR ASPHALT ❑3 YINYLWRAP ❑4 FIBERGLASS REINFORCFOPLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A(U2 &NGLE 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 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER �/.. LEAK DETECTION SYSTEM , CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECSIONTESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED L 1'+�FD(MOIYR) 2. ESTIMATED DUAN TY OF 3.WAS TANK FIL D WITH SUBSTANC IAIN INERTM TE L? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, (S TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o l /,)P I d I o E[ CURRENT LOCAL AGENCY FACILITY ID q AP ROPED BY AME PHONE M WITH AREA CODE LIA-I� PERMIT NUMBER PERMIT APPROVAL DATE PE MIT EXPIR TION DATE CHECK 6 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: lf" 1�J FORM B(6-29-sal THIS FORM MUST BE ACCOMPANIE BY A FACILITYISITE APPLICATION, FORM `A',UNLE5 RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY