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1 <br /> STATE OF CAUFOFM <br /> STATE WATER RESOURCES CONTROL BOARD ^ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM 8 <br /> COMPLETE A SEPARATE FORM FOR TANK SYSTEM. <br /> MARK'ONLY t NEW PERMIT (C 3 RENEWAL PERMIT 5 04ANM OF INFORMATION 7 PERMAN v SND i <br /> ONE ITEM 2 INTERIM PERMIT n A AMENDED PERMIT �'I 6 TEMPORARY TAW CLOSURE <br /> r <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: )g Q,L p FAL <br /> I. TANK DESCRIPTION COME ALL Imus-SPECIFY IF UNKNOWN <br /> A.OWNER'S TANK t.D.f 3.(AK,1L.—R. IL MANUFACTURED 8Y: U 1+1Y(A.lt,fr.L�. <br /> C. OATS INSTALLED(MCIOAYNYEAR) Q V �-7 Q TANK CAPACITY IN GALLONS: <br /> II.TANK CONTENTS IFA-11SMARKED.COMPLS—MITEMM <br /> L �yr't MOTOR VEHICLE FUEL a OILUIVI£AOED 1 1 ] DIESEL 6 AVIATICN GAS <br /> i� 2 PETROLEUM 3C E1uP1'f L 1� 1 Pfi000CT (�j tb PREMIUM ! 7 METHAL <br /> u UNLEADED5 .!E'P FUEL <br /> 2 CHEMICAL PROOUCT 95 UNKNOWNI 2 WASTE C! 2 LEADED El <br /> 99 OTHER (OESC;;ME !N ITEM 0. BELOW) <br /> 0: IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C s <br /> ill. TANK CONSTRUCTION MARK ONE ITEM ONLY 1N BOXES A.S.ANO Q ANO ALL THAT APP<_Ss tN SOX 0 AND E <br /> A. TYPE OF Q I DOUBLE WALL 3 SINGLE WALL.wIIH EXTERIOR LINER Q 95 UNKNOWN <br /> SYSTEM C�2 SINGLE WALL 4 SECONDARY CONTAINMENT (VAuL,mTANK) C 99 OTHER <br /> S. TANK �� t BARE STEELi� 2 STAINLESS arE-: j„�3 �;aERGLAss a STEEL r„AD wNFFBE9c,Lass nE6NFORcc9Pf.As;.c <br /> MATERIAL C 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ISI 7 ALUMINUM C 6 iw%METHANOL COMPATTBLE'nNIFRP <br /> (Primary Tank) 71 9 3RONZE to GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 7-1 t AUBBER LINED Cj 2 ALKYO LINING � 3 ?OXY LNUW; � a PHENOLIC LININ <br /> C.I R <br /> LINING L 5 GLASS LINING �i.rg UNLwo CI 95 UNKNOWN ® 49 OTHER <br /> IS LINING MATERIAL COMPATIBI_WITH JCo%.VETkANCL? YES a No_ <br /> 0.CORROSION F7 1 POLYETHYLENE WRAP C 2 COATING 3 VINYL WRAP CV(�a RRErRGLASS iaEINFORCED PL.AS..0 <br /> PROTECTION C s cATRIOo1cPR0TECTICN C 91 NONE 95 umOK;wN 99 armER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNOERGROUN0,30THIFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PgESSURE A U 3 GRAVITY A U 99 OTHER <br /> S. CONSTRUCTION A U t SINLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND Aio 1 BARE S.`.:L A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLOROE(PVC)A U a FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL VW COATING A U a IW%METHANOL COMPATIBLE wiF:,P <br /> PROTECTION A U 9 GALVANUM STE-=— A U 10 CATHODIO PROTECTION A U 95 UNKNOWN <br /> A u 99 OTHER <br /> 0. LEAK DETECTION Cj li AuTOMATIcLNELEAKoEfEc.mR C6-:r-2LNE TIGHTNESSTESTWG XTERWwL <br /> WOMTORM 0 gg <br /> V.TANK LEAK DETECTION <br /> i ✓�1 VISUAL CHECK ❑ 2 INVENTORY REL;t=.JATION C 3 VAOOZE MONITORING AUTOMATIC TANK GAUGING 5 GROUNO WATER MONITORING <br /> i I„-' TANK TESTING 7 INTERSTMALMONITORM 91 NONE 95 UNKNOWN C'j 9g OTHER <br /> VI.I ANK CLOSURE INFORMATION <br /> ESTIMATED DATE LAST USED(MO/OAYIYR) z ESTIMATED CUANTRY OF I 3.WAS TANK FRLSO WITH yes NO <br /> SUBSTANCE R GALLONS INERT MATERIAL? 77 <br /> i NOS FORM HAS BEEN COMPL.E—IED UNDER PENALTY OF PERJURY,AND TO THE SEST OF MY KNOWLEDGE;,IS TRUE ANO CORRECT <br /> APPLICANT'S NAME / <br /> (PAINTED 6 SIGNAru OATS <br /> 1 (� <br /> LOCAL AGENCY USE ONLY THE STATE I.O.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW v / _ —��'�4= <br /> 'InC^uLINTY x JURISDICTION r FAC:L TANK S <br /> STATE I.D.T U',, <br /> 1 • T <br /> ?5RMIT NUNABER PERMIT AppqCVED BYNDAT=- P=r'GAIT cc-APIRATION DATE <br /> i Fl <br />;-CRM 3 (7-91) THIS FORM MUST 3E ACCOMPANIED BY A PERMIT APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BE_E..N FILED. <br /> /'i/ ICROCStB:.S <br />