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- e STATE OF CALIFOMIA �� *""'• STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B l COMPLETE A SEPARATE FORM FOR EA,CH TANK SYSTEM. MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT C] S CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED ONSITE (( ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED. ,. I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.a Unknown B. MANUFACTURED BY: Unknown lr C. DATE INSTALLED(MO/DAYNEAR) Unknown D. TAN% CAPACITY IN GALLONS; 300 gallons p If.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. I A I MOTOR VEHICLE FUEL 0 4 OIL B. Q to REGULAR UNLEADED 3 DIESEL Q 6 AVIATION GAS 2 PETROLEUM a 80 EMPTY ® 1 PRODUCT 0 is M�IDGRADE UMIUM NLEADED D 5 JEADED 4 ST FUEL ❑ 8 M85 METHANOL a 3 CHEMICAL PRODUCT a 95 UNKNOWN 111 2 WASTE ® 2 LEADED 99 OTHER(DESCRIBE W ITEM D.g0.0YYJ D. IF(At)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 THAW APPLIES IN BOX D AND E I F A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR UNER 5 INTERNAL BLADDER SYSTEM 0 95 UNKNOWN SYSTEM ® 2 SINGLE WALL 0 4 SINGLE WALL IN A VAULT 99 OTHER kt B. TANK ® 1 BARE STEEL 2 STAINLESS STEEL O 3 FIBERGLASS 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC MATERIAL 0 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100. METHANOL COMPATIBLE WIFRP (P(imary Tank) 9 BRONZE 0 to GALVANIZED STEEL 95 bNKNOWN 99 OTHER C.INTERIOR I RUBBER LINED 2 ALKYD LINING E] 3 EPDXY LINING 4 PHENOLIC LINING LINING OR 0 5 GLASS LINING 6 UNLINED 95 UNKNOWN Q 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100. METHANOL 7 YES— NO— D.EXTERIOR 1 POLYETHYLENE WRAP 2 COATING ❑ 3 V�NYL WRAP 4 FIBERGLASS REINFORCED PLASTIC r CORROSION PROTECTION 5 CATHODIC PROTECTION 91 NONE 095 UNKNOWN [:D99 OTHER 1 SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO .- IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,60TH IF APPLICABLE A. SYSTEM TYPE A tb 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 10 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 0 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W1 COATING A U 8 100% METHANOL COMPATIBLE W1FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER LDD. LEAK DETECTION 1 MECNN4CAL LINE tM 2 UK na INESS 3 CCNTw MS INTERSTMAL 4 ELECTROMC UNE 5 AUT011ATIC PUW . LEAK DETECTIONO DETECt011 TEST04 a MONTORM LEAK DETECTOR SHUTOONM 99 OTHER V.TANK LEAK DETECTION 0 1 VISUAL CHECK 2 MANUAL RECONCILIATION ❑ 3 MONITORING 4 GAUGING AUTOMATIC TANK a 5 MONITORINGGROUND �e $nNLGTANK F 7 CONTINUOUS INTERSTITIAL E] 6 SIR 9 WEEKLY MANUAL 10 MONTHLY TANK ® 95 UNKNOWN 99 OTHER MONITORING TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED URED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH J�7'y � �^'�' SUBSTANCE REMAINING Unknown GALLONS IN MATERIAL 7 YES NO THIS FORM HAS BEEN COMPLETED UNDER I=NALTY OF PERJURY,ANP TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME d Th 4r ent for 'Fri St Ir Homes, LLC DATE 5/21/97 F (PRINTLOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS C POSED OF THE:FOUR NUMBERS BELOW COUNTY N JURISDICTION N FACILITY N TANK N STATE LD:# I I ILJ .r 1 11 1 1 * PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE F 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 FORA SHOULD BE ACCOMPANIED BY A PLOT PLAN. RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMS (b95) i i