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0 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 8 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 4A MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATLON 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSUREYANK R .1 `. -7 i OBA OR FACILITY NAME WHERE TANK IS INSTALLED: G (L 4 L I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER5 TANK I. D. x `4. l I�- OZ I & MANUFACTURED BY: UTI L rows C. DATE INSTALLED (MOA3AY/YEAP) 17C) D. TANK CAPACITY IN GALLONS: It. IANR LJUNICINIC) IFA -1 lP mnnncv,1..n•1a•.."_^'_• I� to REG" UNLEADED 3 DIESEL ❑ 8 AVIATION GAS 1 MOTOR VEHICLE FUEL ❑ 4 OIL & PRODUCT C. 7 111 PREMIUM UNLEADED I METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 ❑ 99 OTHER �= T to MIDGIME UNLEADED 5 JET FUEL ❑ a MBS L❑J ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN c:1 2 WASTE ❑ 3 FIBERGLASS 2 LEADED 99 OTHERMESCIBENREMD.SELOM 0. IF (A.1) IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C. A. S. x: III. IANR LiUN011I mnnn.,ncu�.•....... ....._..__.. _.. _.__.. A. SYSTEM TYPE ❑1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF SYSTEM ® 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 1 SINGLE WALL ® 1 BARE STSQ ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE (❑ T ALUMINUM ❑ 8 100E METHANOL COMPATIBLE WIMP MATERIAL (PHmmy Tank)❑ IJ 9 BRONZE ❑ 10 GALVANIZED STEE ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED 9S UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH IOD-- METHANOL? YES— NO_ O. EXTERIOR 1 PO-YETHYL.ENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION �^ CATHODIC PROTECTION 42 91 NONE u ❑ 95 UNKNOWN ❑ 99 OTHER PROTECTION L-1 5 INSTALLED (YEAR) OVERFILLPREVE1I EQUIPMENT INSTALLED(YEAR) SPILLCONTAINMENT E. SPILL AND OVERFILL, etc. DROP TUBE YES _ NO _ STRIKER PLATE YES _ NO _ DISPENSER CONTAINMENT YES _ NO IV. YIYINIa I141'VITI91N I wn 1111) .. _ . _- - - A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING 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 CORROSION PROTECTION A V1 A U A U BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A U 2 STAINLESS STEEL A U A U 8 CONCRETE A U A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLOieDE (PVC)A U 6 FIBERGLASS PIPE T STEPS. WICOATTNG A U 8 100,. METHANOL COMPATIBLE W/FRP A U 95 UNKNOWN A U 99 OTHER D. LEAK OETECTION Q 1 MiCWIaCJI IAIE lF.AY.2 pEfEC.09 NNE 11GVInk45 it 7 GdiNUWS MIEPSTn111 �I 4 D£C:POMC 11E ❑ resn119 LJ ypIRWIG ��J y'.yT�IdI s MIIOWnc PIAP 99 O1HER 9N1W1'a/ V. IAINK LEAAR ucl— i— ❑ 1 VISUAL CHECK U 2 RECONCILIATIONINVENTORY ❑ 3 MONIITORING 4 GAUGING TANK ❑ 5 MONITNORINGTER ❑ 8 TESTING TANK ❑ T MONITORING ONITOR U INTERSTITIAL ❑ 8 SIR ❑ 9 TAW NEK GA G NGAL ❑ f0 TESTINGO -ILY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE N.PLACE) t. ESTIMATED GATE LOST USED (MO/OAY/YR) I L ESTIMATED OUANTITY OF I 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL . THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT TANK OWNERS NAME 1 �2 (JI ay" -0 n� DATE �'/te��ll Tyr J' i tv `�i7 (PRINTEDA SIGNATUPE) ` rU _/"r"YCi•' � � T7X aM/� �1 LOCAL AGENCY USE ONLY THE STATE I.D. BER IS MPOSED OF THE FOUR NUMBERS BELOW COUNTY x JURISDICTION x FACILITY x �Y TANK x44 ' STATE I.D.9 7 t L_L_J =,� C 16 11 L ^......�I PERMIT EXPIRATION DATE �/. THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPUrFORMA. UNLESS A CURRENT FORM A HAS BEEN FILED. FC-' ST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BEACCOMPANIED8YAPLOTP &E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE, BUND STORAGE TANK REGULATIONS FORM B 1895)