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STATE OF CALIFORNIA *`�•••••. STATE WATER RESOURCES CONTROL BOARD i ~� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 8 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT a 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSUREISI[' 8 TANK REMOVED DDA OR FACILITY NAME WHERE TANK IS INSTALLED: ur Y ` G��S �\ I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A OWNERS TANK I.D.0 J B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) �J 0. TANK CAPACITY IN GALLONS: U II,TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. p� 1 MOTOR VEHICLE FUEL ❑ 4 OIL g, O. ❑ to REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS O 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREW M UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 yygy- ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM a BELOV) 0. IF(A-1)1S NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.0: 3 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER El 5 INTERNAL BLADDER SYSTEM �[1 I 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER Y� i B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEWimp (Prl-wy Twit) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR =❑ 5 GLASS LINING ❑ 6 UNLINED J;� 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10054 METHANOL? YES____ NO— D.EXTERIOR 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER F-SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER I B, CONSTRUCTION A U 1 SINGLE WALL A U 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8,1001/6 METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:]1 1¢CNMIILAL LIME LEAK 2 LINE TIGMNE55 3 CCNTwLVL S KMMTMAL 1 ELECMOMC UNE 0 5 AUTOMATIC PlJMP DMCT9R AIO❑ TESTMONTORMG mm CETECTOR SHUMOwM El 99 OTHER V.TANK LEAK DETECTION ` ❑ 1 VISUAL CHECK ❑ 2 MANRECOUAL CIUATIONORY ❑ 3 MONITORING ❑ 4 GAUGG AUTOMATIC TANK ❑5 MONTORINGOUND T ❑fi TESTING ❑ 7 hC100lNITNORING INTERSTITIAL ❑ 8 SIR ❑ 9 K GAUGING ❑10 MONTHLY O TTHL TANK ❑ 95 UNKNOWN ❑ 99 OTHER ING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) I.ESTIMATED DA LAST USE (MOIDAYNR) 2.ESTIMATED QUANTITY OF -}(} ID 3-WAS TANK FILLED WITH SUBSTANCE REMAINING ONS INERT MATERIAL 7 YESjefs NO a THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TH EST O KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME1 DATE (PRUYTED 6 SIGNATURE) l7; i --�-- _ / /C o LOCAL AGENCY USE ONLY THE STATE E.D.NUMBER IS COMPQSED OF THE FOUR NUMBER$BE OW COUNTY# JURISDICTION# -FACIUTY N TANK# STATE I.Dl m PERMIT NUMBER PERMIT APPROVED BYlDATE PERMIT EXPIRATION DATE 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 SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM 1NfTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (8•BS) 1i iI