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STATE OF CANPORMA >• STATE WATER RESOURCES CONTROL BOARD i4 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B .�� =e C I,�D„ COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ f AMENDED PERMIT E-] ! TEMPORARY TANK CLOSURE a TANK REMOVED/')(„ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Tri to Homes, `/ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) Unknown D. TANK CAPACITY N GALLONS: 800 gallons ILTANKCONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. AR A 1 MOTDR VEHICLE FUEL ❑ 4 OIL B. C. �1 1fUNLEADED 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT ❑ ib PREMIUM 4 aSAHOL ❑ 7 METHANOL UNLEADED E] 3 CHEMICAL PRODUCT El 95 LEADED 95 UNKNOWN 2 WASTE ❑ 99JET L OTHER (DESCRIBE IN ITEM D. BELO" D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOK D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER S. TANK ® 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 9 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 90 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LININGe UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING Tnr IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION [j] 91 NONE F-1 95 UNKNOWN ❑ 09 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) none OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) none IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A lb i SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U W OTHER C. MATERIAL AND A 0 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 9 CONCRETE A U 7 STEEL WICOATING A U 9 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTION A U 95 UNKNOWN A U 90 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MOKROIVNG 00 OTHER none V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 9 TANK TESTING ❑ 7 INTERSTITIAL MONITORING Z] 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMA0 DATE LAST USED IMOIDAY/YRI 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO nknown SUBSTANCE REMAINING Unknown GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLET D UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME Ric ore for Tri Star Homes IRRINTED 13�GNaTURE1 1 DATE5/21/C3'l LOCAL AGENCY USE ONLV THE STATE I.D.NUMBER IS C POSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION• FACILITY 9 TANK# STATE I.D.# m = y+ PERMIT NUMBER PERMIT APPROVED BY/DATE PERM IT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (1291) \� FOROWSM V�