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STAT~OF CALIFORNIA � •� .,,r STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 8 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ k NEN! PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFCFMMTION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHEIIE TANK IS INSTALLED: f. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.A B, MANUFACTURED BY: C. DATE INSTALLED(MO'D.AYN AR) + O O. TANK CAPACITY IN GALLONS: Do c-n IL TANK CONTENTS IF A•1 IS MARKED,COMPLETE(TEM C. A. 1 MOTOR VEHICLE FUEL OIL B, C, la REOJLAR UNLEADED 3 DIESEL C 8 AVIATIONGAS 2 PETxQ1-EDM BD EMPTY 1 PRODUCT 14 PREMIUM UNLEADED A GASAHOL E] 7 METHANOL ❑ It.MCGRADE LMEAQED 5 JETFUEL B Mm ❑' 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 pTMER(DE9CRSBE RI ffVi D.BEE.DW) D. IF(A,1)I9 NOT MARKED, LATER NAME OF SUBSTANCE STORED u C.A S.0 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,ANO ALLTHAT APPUE3 IN Box D AND E A.TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ A SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK D 1 BAAE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ A STEEL CLAD WI FIBERGLASS REINFORCED PLAbTIC MATERIAL ❑ S CONCRETE ❑ 8 POLYVINYL CTILORIGE ❑ 7 ALUMINUM ❑ 8 100`x METHANOL CCMPA7TBLE WlFRP (Pnnary Tank) rf❑�- 9 BRONZE ❑ 10 GALVAN#ZED GTEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR L 1 I RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING LINING OR ❑ 5 GLASS LINING e UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH ID(1TI. METHANOL? YES_ N4___- D.EXTERIOR 1 POLYETHYLENE WRAP © 7 COA71NG ❑ 3 VINYL WRAP �4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPIV.CONTAINMENT INSTALLED(YEAR) OVERFIILPREVENTION EQUIPMENT IN67ALL€D(YEAR) } DROP TUBE YES NO STRIK -R-PLATE YES W 016PENSER CONTAMMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUNO OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A ID2 PRESSURE A U 3 GRAVITY A U A FLEXIBLE PFPIN43 A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALL A Q2 DOU51.E WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTIKEft C. MATERIAL AND A U I BARE MCL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A (E, F BERGLABS PIP CORROSION A U E ALUMINUM A U a CONCRETE A U 7 STEEL WI COATING A U 9 IW% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER O, LEAK DETECTION i 'III 2 L"t�KTw" ❑3 W.,.3 vmftm u �E etclncNc LOE �6 aurawns Puw DETECIDN fE_41M SIONT<rm R NM ❑ 9'9 OTHER. V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY E] J[1 3 VADOZE 1 A AUTOMATIC TANK ❑ 5 GROUND WATER ❑ 8 ANNU,ALTANK RECONCILIATION MONITORING GAUGING MONITORING TEsnN4 7 MON INUOU INTERSTITIAL ❑ 9 SIR ❑ B WEEKLY MANUAL ❑ 10 MONTHLY TANK E] 95 UNKNOWN © 1i9 O'T}IER VI.TANK CLOSURE INFORMATION(PEAMANENT cL09UAG IN.PLACE) 1.ESTIMATED GATE LAST USED(MO/DAYNR) 2,MIMATEO OUANTTTY OF 3,WAS TANK FELLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 71415 FOAM HAS BEEN COMPL ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANT)60RREC7 TANK OWNERS NAME t DATE (PR1NT$li a 61;NATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMISFA IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY! JURISDICTION 0 FACILITY I TANK is STATE I.Dl ❑ PERMIT NUMBER PERMIT APPROVED BYMATE PEFUq"T'ExPIRAf10N UMTS THIS PORN MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED, FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLElIFXMG THE UNDERGROUND STORAGE TANK REGULATIONS PGRM 9 *95)