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STATEOFCAUFORMIA STATE WATER RESOURCES CONTROL BOARD W 4a , UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM 8 3 oa iu . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REM DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L4511Qj I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN YiA 1 A.'OWNER'S TANK I.D.x /�, B. MANUFACTURED BY:—rbfa i I lq C. DATE INSTALLED(MO/DAY/YEAR) (,,I1Q is ' D. TANK CAPACITY IN GALLONS: 'G• ttt II.TANK C/NTENTS IFA-1 IS MARKED,COMPLETE ITEM C. q 1 MOTOR VEHICLE FUEL ❑ 4 OILg• Cwr to REGULAR 3 DIESEL ❑ 6 AVIATION GAS . EEUNLEADED q GASAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1bUPREMIUM NLEADED ❑ 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 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.A III. TANK CONSTR TION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM8 100% METHANOL OMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING V95 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING ❑ 6 UNLINED UNKNOWN ❑ 99 OTHER LINING N� IS NTNG MATERIAL COMPATIBLE WITH 100"/6 METHANOL? YES_ NO-!,/UMt%,� -A D.CORROSION 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 LINK OWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) 1 C VERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PPRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 1006/6 METHANOL COMPATIBLE W/FRP PROTECTION A V GALVANIZED STEEL A U /0 CATHODIC PROTECTION A U 95 UNKNOW A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING3 INTERSTIT IAL MONRORWG ❑ 99 OTHER V.TANK LEAK DETECTION ❑F1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER Vi.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATEfj1 (PRINTED 8 SIGNATURE) "6 v LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW I COUNTY# JURISDICTION# A&i8 TANK#7 STATE I.D.# = j 2 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �� FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (12.91) �j �� I f ��