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STATE OF CALIFORNIA '«s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - CORM 8 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ ONE ITEM ❑ 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SI ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 0 V/-- 'L:I- 4t.11l I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# S�ANUFACTURTEYD SY��A� I C. DATE INSTALLED(MO/DAYIYEAR) Ld [a7 APACIIN GALLONS: , 11.TANK 'CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL g. C 1a REGULAR UNLEADED 2 PETROLEUM ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 60 EMPTY N4 PRODUCT 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL LEADE ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE is DE UNLEADED ❑ 5 JET FUEL ❑ 6 MB5 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.SELOM D. IF(A.1)IS NOT MgRKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#; III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR UNER ❑ SYSTEM 2 SINGLE WALL ❑ 5 INTERNAL BLADDER SYSTEM 4 ❑ 95 UNKNOWN $fNGLE WALL IN A VAULT ED99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS MATERIAL MATERIAL ❑ 5 CONCRETE STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC (Primary Tank) ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN Q 99 OTHER C.INTERIOR L❑J 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ LINING OR ❑ 5 GLASS LINING 6 UNLINED ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING COATING 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO, o.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING CORROSION ❑ 3 VINYL WRAP .4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,@{0• SPILL CONTAIN MENTI STALLED(YEAR) I OVERFILL P EVI'NTION EQUIPMENT INSTALLED{YEAR) DROP TUBE YES NO STRIKER PLATE YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE DISPENSER CONTAINMENT YES NO A. SYSTEM TYPE A U 1 sUcTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 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)A FIBERGLASS PIPE CORROSION d U 5 ALUMINUM A U 6 CONCRETE CORRECTION A U 7 STEEL W/COATING A U 6 100! METHANOL COMPATIBLE W/FRP A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION MEGHAMCAL LINE LEAK �2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL ❑4 ELECTRONIC LIkE 5 AUTOMATG PUMP 71— DETECTOR TESTING ASONPTORING LEAK DETECTOR SRUTppWN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL'INVENTORY ❑ 3 VADOZE ❑ 4 AUTOMATIC TANK O 5 GROUND WATER f� 6 ANNUALTANK 7 CONTINUOUS INTERSTITIAL MONITORING GAUGING MONITOHING L-J TESTING MONITORING ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN TANK GAUGING TESTING ❑99 OTHER VI-TANK CLOSURE INFORMATION(PERMANENT CLOSURE (N-PLACE) 1,ESTIMATED DATE LAST USED(MO/DAYlYR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL 7 YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,!S TRUE AND CORRECT TANK OWNER'S NAME. (PRINTED 6 SIGNATURE} LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW DATE 7� COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.4 PERMIT NUMBER RMIT APPROVED SYMATE PERMIT EXPIRATION DATE 7 THIS FORM 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 FORM B (6-95) SHOULD BE ACCOMPANIED BY A PLOT PILE THIS FARM WITH THE LOCAL AGENCY IMPLEMENTING TH7VRGROUND STORAGE TANK REGULATIONS