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CA-039 Tank 1 - STATE OF CALIFORMA STATE WATER RESOURCES CONTROL BOARD iy '- UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ' n s 14 MARK ONLY ® I NEW PERMIT Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ❑ 7 R NTLY CLOSED ONSITE ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE O 9 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Stockton, CA I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• DD 1 B. MANUFACTURED BY: Modern Welding C. DATE INSTALLED(MO/DAYNEAR) 9/15/95 D. TANK CAPACITY IN GALLONS: 20,000 II.TAN KCONT ENTS IFA-1 IS MARKED,COMPLETE ITEM C. A O 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1aUNLEADED DIESEL ❑ 8 METHANOL AVIATION GAS ❑ 2 PETROLEUM ❑ BO EMPTY ❑ 1 PRODUCT O 1DUNLEADED ❑ 5 JET FUEL ❑ ] METHANOL O 3 CHEMICALPRODUCT ❑ 95 UNKNOWN O 2 WASTE O 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.8.AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN SYSTEM ® 2 SINGLE WALL a 4 SECONDARY CONTAINMENT (VAULTED TAN19 ❑ M OTHER B. TANK ❑ 1 BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL F-] 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ ] ALUMINUM a 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank( ❑ B BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR O 5 GLASS LINING ® 8 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 O95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) S OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 9 IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE 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&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 B CONCRETE A U 7 STEEL W/COATING A U B IDD% METHANOL COMPA�%TIBLE W/FRP PROTECTION A, GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A(U)00 OTHER ENg/Q-r-1 �—� D. LEAK DETECTION [ ' AUTOMATIC LINE LEAK DETECTOR F] 2 LINE TGHTNESS TESTING MONROIIING ❑ W OTHER( V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING CRr4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 8 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ M OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANPSNAMEMarc en PATEC� RINTEDa SWNATUREI V.P. Snvir. Serv. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION 9 FACILITY 9 TANK 9 STATE I.D.# PERMITNUMBER PERMITAROVED V TE PERMIT EXPIRATIONDATE P 9119 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. yJ( FILE THIS FORM WITH THF I OCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (1291) ` ^ FOROa%BRE 3 3 '� 0 g-�a- Y8 0 of (HJ