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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM 8 COMPLETE A SEPARATE FORM FOR H TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El ] p NTLY LOBED ONE REM F-12 INTERIM PERMIT ❑ d AMENDED PEAMR ❑ g TEMPORARY TANK CLOSURE ❑ 8 Y OyE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS_ SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY, C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK NTENT.S IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ d OIL B. C, T� is REGULAR UNLEADED 3 DIESEL ❑ AAWATIONGAS ❑ 2 PETROLEUM ❑ g0 EMPTY E Rl C. u lb PRQIII.M UNLEADED s GTFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPROQUCT ❑ 95 UNKNOWN ❑ 2 WASTE Ie MIDGRADE UNLEADED I� 5 JET FUEL ❑ aM85 ❑ 2 LEADED IL�JI 99 OTHER(DESCRIBE IN REM D.BEL01'v) D. IF(A 1)IS NOT MARIG=D. ENTER NAME OF SUBSTANCE STORED - C.A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPUES 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 ❑ d SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ d PHENOLIC UNING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001116 METHANOL? YES_ NO— D. O_RIOR D CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BLC. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLER(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT YES_ NO_ IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNDERGROUND.BOTH IFAPPUCABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U d FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED 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 U s FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W1 COATING A U 8 IOD% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:]I MEDMMca—LFAIc 2 uxE iIEHRa:ss a 3 Garrlm:ws wrtAslnul ❑d BECTRUac LuaE ❑s Aumwnc PBM+ oETEaoa n[mxp #oNIaBmG IFAK aE1ECTpR 9Alloown ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 ❑ MANUUALINVENTORY ❑ 3VA7 ❑ d C TANK ❑ 5 D WATER ❑ eANNUALTANK 7NINTERSTITIAL RpRING GAUGING MONITORINGMONITORING F-1 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE? 1.ESTIMATED DATE LAST USED(MO/DAWYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ElNO❑ 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 OWNER'S NAME DATE (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY R TANK# STATE I.D:# '22f FT-F-1Z O Z U b PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE l THIS FORM MUST BE ACCOMPANIED BY A PERMR APPLICATION-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONFORMI'�I�U SHOULD BE ACCOMPANIED BY A PLOT PI' I.E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE I" ;ROUND STORAGE TANK REGULATIONS 11`` FORMS (695) " `_