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STATE OF CALIFORNIA "^y STATE WATER RESOURCES CONTROL BOARDS ' UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM 8ab COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ I NEW PERMIT F73 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE ❑ 0 TANK REMOVED DBA OR FAGLITY NAME WHERE TANK I$INSTALLED. (��1 At- 1. TANK DESCRIPTION COMPLETE ALL ITEMS_ SPECIFY IF UNKNOWN A. OWNERS TANK I.D.R M MANUFACTURED BY: C, DATE INSTALLED(MODAY/YEARjAp o D, TANK CAPACTTY IN GALLONS' ©� II.TANK CONTENTS IFA-I IS MARKED,COMPLETE ITEM C. A I MOTOR VEHICLE FUEL Q 4 OIL E C. 1. RE ULAA LRJLWW 3 DIESEL ❑ 0 AVIATION OAS 3 A 1b PRE>v4JI4 UNLFADEO 4 GASAHOL ❑ 7 MET7iANOL ❑ 2 PMOCHEMI J UM ❑ 60 PTY t PRODUCT F❑ le MS E 5 JET FUEL ❑ B MHS ❑ 3 CI�EMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED —E 99 OTHER(DES(RTBE IN ITFJ/o.BE-ow) D. IF(+11)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C_A.3.R III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL.THAT APPLIES IN BOX D AND E A, TYPE OF I DOUBLE WALL ❑ 3 SJNGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL.BIADCEA SYSTEM ❑ 96 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL W A VAULT ❑ 99 OTHER B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL X 3 FIBERGLASS ❑ 4 STEEL CLAD WI RBIFROLASS REINFOACED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE 7 ALUMINUM ❑ 5 100% METHANOL COMPATIBLE W1FRP (F►loYTwk) ❑ 9 BRONZE ❑ 10 GA'LVAMZED STEEL ❑ 95 UNKNOWN ❑ 0o OTHER C.INTERIOR ❑ I RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LIMING OR ❑ S GLASS LIKING B UNLINED ❑ 95 UNKNOWN ❑ li9 OTHFR COATING IS LINING MATERIAL COMPATIBLE WITH IOVA METHANOL 7 YEs— NO— R,EXTERIOR ❑ 1 POLYIETHYL eNE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP � 4 FIBERGLASS REEINFORCED PLASTIC CORROSION '^^-� LES ROTECTION ❑ 7 CATHODIC PROTECTION ❑ 9t NONE ❑' 96 UNKNOWN 99 OTHER PILL AHD OVERFILL etC SPILL CONTAINMENT INSTALLED(YEAq) OVERFILL PREVENTION EOUNPMENT INSTALLED(YFARI DROP TUBE YES NO STRI R LATE YES NO DISPENSER CONTAINME T YES NO IV,PIPING INFORMATION CIRCLE A IF ABOVE©ROUND OR U 19 UNDERGROUND,BOTH IF APPUCADLE A. SYSTEM TYPE A U I SUCTION As U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 CfTmoi 9. CONSTRUCTION A U 1 SINGLE WALL A(p 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)<D A FIBERGLASS PIPE CORROSION A U a ALUMINUM A U 6 CCNCSM A U T STEEL WICOATING A V 8 100% METHANOL OOMPAT(BLE W/FRP PROTEnON A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A V P9 OTHER D. LEAK DETECTION1 wllll tm owe 2 U-e mK,,&ss s carouses PI15117MAL +aWTP4 a UNE 6 AIlSDMMTIC vVII aET4CUL4lCAL 1SIRIO ❑ NUhtQ�NO ❑ l OrT'IGf01E ❑ 99 an�EH V.TANK LEAK DETECTION [ /I ❑ f VISUAL GHECK ❑ 2 RECONCILIATION MANUAL d ❑ 3 MON ITZORIka 4 GUGINa AUTOMATIC TANK ❑S MONITORING WATERGROUND E] Ii TEsnN®TANx ❑ 7 CON TORINUOU INTeA=,kL ❑ B SIR ❑ 2 WEEKLY MANUAL El 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IMPLACE) 1,E$TIMATED DATE LAST USED IMO/OAY/YR) 2.ESTLMATED dVANTTTY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE$EST OF MY KNOWLEDGE, IS TRUE AND CORRECT TAW OWNER'S NAME DATE tan WTtD A e awATURE) LOCAL AGENCY USE ONLY THE STATE I.D,NUMBER IB COMPOSED OF THE FOUR NUMBERS BELOW COUNTY M JURISMCTION II FACILITY k TANK K STATE I.Dl PERMIT NUMBER PERMIT APPROVED EYMATE PERMIT EXPIRATION DATE THIS FORM MUST OF ACCOMPANIED BY A PERMIT APPLICATION•FORE( UNI FSS A CURRENT FORM A HAS BEEN FILED, FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS F13Rm SHOULD BE ACCOMPANIED BY A PLOT PLAN. BILE THIS FORM WITH THE LOCAL AGENCY ILPLEMENTM THE UNDERGROUND STORAGE TANK RECIULATIONS FORM a (GG5)