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• STATE OF CALIFORNIA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 8 COMPLETE A SEPARATE FORM FOR E ANK SYSTEM. 1 NEW PERMIT ❑ 7 PERMANENTLY CLOS TE MARK ONLY ❑ J RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE REM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.#��7 I B. MANUFACTUR 0 BY: D. TANK CAPACITY IN GALLONS: I/ C. DATE INSTALLED(MO/DAY/YEAR) II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C- 6 AVIATION GAS to REGULAR UNLEADED ❑ 3 DIESEL ❑ A t MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. ❑ +b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ BO EMPTY 1 PROOUCT ❑ IO MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.SELOM D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.3,AND C.AND ALL THAT APPLIES IN BOX D AND ❑ i UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN A. TYPE OF ❑ 99 OTHER SYSTEM 2 SINF7GLE WALL 4 SINGLE WALL IN A VAULT t BARE STEEL ❑ 2 STAINLESS STEEL F73 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ B 100% METHANOL COMPATIBLE W AFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F71 RUBBER LINED ❑ '0 UNING E] 3 EPDXY UNING El PHENOLIC LINING C.INTERIOR 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING OR F75 GLASS LINING EZ COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ 0.EXTERIOR ❑ 1 POLYETHYLENE WRAP 7] 2 C NG ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION gt NONE ❑95 UNKNOWN ❑ 99 OTHER PROTECTION F75 CATHODICPROTEC'nON - SPILLCONTAINMENT INSTALLED(YEAR) OVERFlLL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,CTC. DROP TUBE YES NO STRIKER PLATE YES_- NO- DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A� 1 SINGLE WALL A U Z DOUBLE WALL A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER YL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVIN CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 95 UNKNOWN A U 99 OTHER J CWrPV WS WfERSrmAL 4 RJECTRO UNE ❑5 AIROIMPC MW E] 99 OTHER D. LEAK DETECTION [:11 xECW OR'UNE IFAK ❑2 UNE nGHrNE55 � WRIMM OF K OE =R SNUmOWN OETECfO V.TANK LEAK DETECTION kTEF ANNUALTANK 2 MANUAL INVENTORY ❑ 3 MONOTOPING ❑ 4 GAUGING AUTOMAMC TANK ❑ 5 GROUND W,MONITORING TESTING ❑ 1 VISUAL CHECK RECONCIUATON ❑ 7 MON TOR U INTERSTITIAL ❑ B SIR ❑ 9 7WpNK GAUGINGAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 2.ESTIMATED QUANTITY OF J.WAS TANK FILLED WITH YES ❑ NO ❑ 1.ESTIMATED DATE LAST USED(MOIDAYNR) 11 SUBSTANCE REMAINING GALLONS I 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 (PRNTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNTY# JURISDICTION# FACILITY# -L.�-=F-� �1 � STATE I.D.# 5 �/¢ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE RM A HAS BEEN FILED. ORM C MUST BE COMPLETED FOR[NST .THIS THIS FORM MU SHOULD BE ACCOMPANIED BY A PLOT RLE THIS FORM WITH THE M A UNLESS A CURRENT OCAL AGENCY IMPLEMENTINGTHF GROUND STORAGE TANK.REG I T�NS>✓• PM /�/, 44 FORM 8 (6-95) �� ,--y �/ 's f�®` J { ( CSA-rig