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• • a STATE OFCALIFORNIA •STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 3 6 Mr S . Ver-kAW C4 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.#©` O- .O' B. MANUFACTURED BY: U i 1 w C. DATE INSTALLED(MO/DAYiYEAR) r D. TANK CAPACITY IN GALLONS: Lo I C)pp ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A �1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. la REGULAR 3 DIESELUNLEADED ❑ 8 AVIATION GAB 2 PETROLEUM ❑ 80 EMPTYPRODUCT ❑ 1b PREMIUM 4 GASAHOL ❑ 7 METHANOL w"' UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) 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.B,AND C,AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Q-Q SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER ❑ B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pflmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL '95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ��yy❑----II 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE AIFASOVE0ROUND, RUIFUNDERGROUND.BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION .A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH p 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 W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3IMMONITORI GL ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER VI,TANK CLOSURE INFORMATION 1.ESTIMATEDD T ST USED(M V/VR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH yES NO SUBSTANCE REMAINING �/ GALLONS INERTMATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY Oq PERJURY,AlVD TOT BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME DATE (PRINTED B SIGNATURE)T \ a• Jl.� , 1O- LOCAL AGENCY USE ONII LY THE STATE I.D.NUMBER IS CVMpnccn 0 THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ® FTT-1 I I I A ( I ?I If I I I I jVL�ehwwy3 PERMIT NUMBER ER PMIT APPROVED BY/DATE PERMIT EXPIRATION DATE 72 FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOROafa&RI