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STATE OF CALIFORNItS WATER RESOURCES CONTRO ARD '. <br /> FORM `8': UNDEHT-,ROUND STORAGE TANK PRO AM =' <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT F-] 3 RENEWALPERMIT 0 5 CHANGE OF INFORMATION �0 7 PERMANENTLY CLOSED T NK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE TANK REMOVED D <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: s, S <S �1/ FAY/R'M_T_ANK-YES❑ NO 7 <br /> IG <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# Md I B. MANUFACTURED BY: U <br /> C. YEAR INSTALLED b D. TANK CAPACITY IN GALLONS: Q W <br /> II. TANK IPONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,C MPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 0 2 LEADED 3 DIESEL P <br /> ❑ 3 CHEMICAL PRODUCT Ej 4 OIL PRODUCT ❑4 GASAHOL E] 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN 2 WASTE D 7 METHANOL [:] 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> All. TANK C1FO---INSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D <br /> A.TYPE OF L�J DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR UNER � 95 UNKNOWN <br /> SYSTEM I CJ `SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEGARON 2 STAINLESS STEEL 3FIBERGLASS E]4STEEL CLAD W/FIBERGLSS REINFORCED PLASTIC <br /> B.TANK F-�5 CONCRETE 6 POLYVINYLCHLORIDE7 LUMINUM 8100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE El 10 GALVANIZED STEEL VUNKNOWN 99 OTHER <br /> 1 RUBBER UNED [:]2 ALKYD LINING 3 EPDXY LININGn 4 fNENOUCUNING <br /> C. INTERIOR 5 GLASS UNING F-16 UNLINED 95 UNKNOWN <br /> LINING <br /> IS UNING MATERIAL COMPATIBLEWTM i00%METHANOL? YES NO 99 OTHER <br /> 0.CORROSION ❑ I POLYETHLENE WRAP F-1 2TAR OR ASPHALT ❑ 3WWLWRAP' ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION [-]91 NONE U6 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER <br /> A U / STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> 8 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONEP S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES DNO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> p0 s-17 1Uoo <br /> CURRENT LOCAL AGENCY FACT TTY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> UVI/tM0 ! <br /> LPERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT AMOUNT URCHARGE AMT. FEE CODE R IPT# BY: <br /> FORM'A',UNLESSA <br /> FORMB(3-7-6B) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, ENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />