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�z° ^ ea <br /> STATE OF CALIFORNIA •� °•. <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMI APPLICATION- FORM B =� 1 a. <br /> 1 <br /> COMPLETE A SEPARATE FORM FOR ACH TANK SYSTEM °"f°""�� <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY TANK CLOSURE ® e TANK REMOVED 157 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 729 So . Commerce Stockton (�� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.a B. MANUFACTURED BY: Unknown <br /> _ <br /> C. DATE INSTALLED(MO/DAYAYEAR) Unknown D. TANK CAPACITY IN GALLONS: 2000 <br /> ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. <br /> A. ® 1 MOTOR VEHICLE FUEL 4 OIL B. C. 1eUNLEAD D 3 DIESEL O 6 AVIATIONGAS <br /> O 2 PETROLEUM � SO EMPTY ® 1 PRODUCT O Ib PREMIUM 4 GASAHOL O 7 METHANOL <br /> 3 CHEMICALPRODUCT O 95 UNKNOWN O 2 LEADED 2 WASTE ® UNLEADED O Y9 JOTHERL(DESCRIBE IN ITEM D. BELOW) <br /> O <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.III: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,ANDC,ANDALLTHAT APPLIES IN BOXD AND <br /> A. TYPE OF © 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) 0 99 OTHER <br /> B. TANK Rr i BARE STEEL O 2 STAINLESS STEEL 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL O 5 CONCRETE O 6 POLYVINYL CHLORIDE O 7 ALUMINUM a B 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) O 9 BRONZE 0 10 GALVANIZED STEEL 0 95 UNKNOWN O 99 OTHER <br /> O 1 RUBBER LINED O 2 ALKYD LINING ❑ 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING ® 6 UNLINED F-1 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— <br /> D.CORROSION 0 1 POLYETHYLENE WRAP ® 2 COATING O 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION Q 91 NONE 95 UNKNOWN 0 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTIONU 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A®9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Q 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING 3MONITORING 99 OTHER <br /> Nnne <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK 0 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING a 4 AUTOMATIC TANK GAUGING O 5 GROUNDWATER MONITORING <br /> 6 TANK TESTING 0 7 INTERSTITIAL MONITORING ® 91 NONE ❑ 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING 20 GALLONS I INERT MATERIAL? YES O NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> IPRINTED a SIGNATURE) Fredrick C . Clarke -ID 12/5/91 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# M <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> 14 � v I NCC-']Z � F <br />