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STATE OF CALIFORNIA t STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM 8 COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ® 3 RENEWAL PERMIT y 5 CHANGE OF INFORMATION ❑ 7 P TLY ED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE ® 8 T ` V OBA OR FACILITY NAME WHERE TANK IS INSTALLED: ,) 1 I 1 r 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.0.f 'I 1 4 ! S. MANUFACTURED BY: C. DATE INSTALLED(MODAWYEAR) `alfl-7 D. TANK CAPACITY IN GALLONS:- 1 11.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OILS. la REGULAR UNLEADED ❑ 3 DIESEL 6 AVIATION GAS ❑ 2 PETROLEUM ❑ so EMPTY 1 PRODUCT 5 lb UNLEADED 4 GASAHOL ❑ 7 METHANOL tc E UNLEADED 5 JET FUEL 8 MBs ® 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ® 2 LEADED 99 OTHER(DESCRIBE IN ITEM 0.BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.e 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF ga 1 DOUBLE WALL ® 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primacy Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL Cl 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ® 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 8 UNLINED ❑ 95 UNKNOWN ❑ N OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 59 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ s CATHOOtCPROTECTION ❑ 91 NONE C]95 UNKNOWN ® 99 OTHER II SPILL CONTAINMENT INSTALLED(YEAR) EA OVERFILL PREVENTION EQUIPMENT INSTALLED(YR) E SPILL AND OVEAFiLL,BIC. 1 DROP TUBE YES N� STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A CT2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL AU 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.04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COAnNG A U 8 100%METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION (�1DETECML° ❑2 3 oaatQa�us a1TERs1nlat E]4 OEM= s vao ❑ 990,.6R V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK [:] 2 RMANUAL ECONC1UA1INVENTORY ® 3 VAOOZF MONLTORING ® 4 AUTOMATIC TANK ®5 GROUND WATERMONITORING ❑8 TANK TESTING 7 CONMaNTINUOUS INTERSTITIAL F] 8 SIR ® g T GAUGINGAL _]10 TME NTTHLY TANK ❑ g5 UNKNOWN 99 OTHER TING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE I 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2 ESTIMATED QUANTITY OFI 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIA.7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED S St/AR1REj -7 - ' 1 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPO UR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# rK STATE 1.01.4 m FTTI PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE �y THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC ATION-FORM A.UNLESS A CURRENT FORM A HAS 13EEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT F RLE THIS FORM WITH THE LOCAL AGENCY ImpLENIENTING THE' 7AGROUND STORAGE TANK REGULATIONS FORMS (8-95) 0 0