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sSTATE Of CAUfORNiA STATE WATER RESOURCES CONTROL BOAR11 UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM 8 COMPLETE A SEPARATE FORM FOR H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED 0 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: az 1. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.9 / 8. MANUFACTURED BY: C. DATE INSTALLED(MO/OAY/YEAR) / 0. TANK CAPACITY IN GALLONS: 11.TANK CWENTS IFA-I IS MARKED.COMPLETE ITEM C. (j 6 AVIATION GAS 3 DIESEL I8 REGULAR � ❑ A 1? 1 MOTOR VEHICLE FUEL 4 OIL 8. C. `—J ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JET FUEL 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE Q 2 LEADED PI99 OTHER (DESCRIBE IN ITEM 0. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x Ill. TANK CO NSTRU ION 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 (V LTED TANK) ❑ 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 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE �❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER I RUBBER LINED ❑ 2 ALKYD LINING =.;96 3 XY LINING ❑ 4 PHENOLIC LINING C.INTERIOR (� 5 GLASS LINING ❑ 6 UNLINED C 95 UNKNOWN ❑ 99 OTHER LINING u IS LINING MATERIAL COMPATIBLE WITH 1001:METHANOL? YES_ NO D.CORROSION ❑ 1 POLYETHYLENE WRAP = 2 COATING = 3 VI L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ,=_f 5 CATHODIC PROTECTION = 91 NONE ❑ 5 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 09 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A©1 SINGLE WALL A U 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 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W1 COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A UA GALVANIZED STEEL A V 10 CATHODIC ROTECTICN A UNKNOWN A U 99 OTHER D. LEAK DETECTION t AUTOMATIC UNE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 9 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION F71 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING F74 AUTOMATIC TANK GAUGING C__ 5 GROUND WATER MONITORING 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 YES —' NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? U ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED d SIGNATURE 12-12-3 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW I97 COUNTY# JURISDICTION It FACILITY# TANK* STATE I.D.; j� p PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 2 ` i / THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORMA,UNLESS A CURRENT FORMA HAS BEEN FILED.c��✓J,�n , FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS U FORM 3 (12.91) FOR RWi