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STATE OFCAUF INA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PEbMIT APPLICATION - FORM B .a 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ® I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 15 CHANGE OF INFORMAT04 ❑ 7 PERMANENTLY CLOSED ONSITE + ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE 0 .6 TANK REMOVED 08A OR FACILITY NAME WHERE TANK IS INSTALLED: Tri St�r Horaegi, (. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK L D.s 9. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) Unknown D. TANK CAPACITY IN GALLONS: 800-gallons II.TANK CONTENTS IFA•iISMARKED,COMPLETE ITEM C. A C I MOTOR VEHICLE FUEL 4 OIL B. ISUNLEAOED a AVIATION GAS REGULAR H 3 DIESEL r� r 4 GASAHOL L,J ` 2 PETROLEUM 60 EMPTY ❑ 1 PRODUCT ❑ 16UNLEAPREMIUM 5 JETFUEL O IC ❑ 7 METHANOL [[[ 3 CHEMICAL PRODUCT a 95 UNKNOWN a 2 WASTE 2 LEADED El 99 OTHER (DESCRIBE IN ITEM D. BELOW( j"- D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED I -C.A.S.i III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX DANE)E A. TYPE OF ❑ I 0009LE WALL ❑ 3 SINGLE WALL WITH EXTERIORS LINER ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (IAULTED TANK) ❑ 99 OTHER 6. TANK ® I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WrFIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 IDD% METHANOL COMPATIBLE WI (PrimlryTAI ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ` 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C.I LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES NO i D.CORROSION ❑ I POLYETHYLENE WRAP a 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC r PROTECTION ❑ 5 CATHODIC PROTECTION Y] 91 NONE ❑95 UNKNOWN ❑ 09 OTHER r [ *. E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) none (OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) none IV. PIPING INFORMATION CIRCLE A IF ABOVE G ROUND OR U IFUNDERGROUND,80THIFAPPLICASLE A. SYSTEM TYPE A I SUCTION A U 2 PRESSURE A U ] GRAVITY � A U o9 OTHER 0. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3i LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A Q1 I 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 71 STEEL W/COATING A PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION R U 95 UNKNOWN A V e 1D0x METHANOL COMPATIBLE wrFRP U 99 OTHER D. LEAK DETECTION [] I AUTOMATIC LINE LEAK DETECTOR [:D 2 LINE TIGHTNESS TESTING ❑ MONRORING ❑99 OTHER none V.TANK LEAK DETECTION I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORlNO O 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING Fx] 91 NONE a 95 UNKNOWN ❑ 99 OTHER F VI.TANK CLOSURE INFORMATION I.ESTIMA D ATE LAST USED IMOlDAYrvR) 2 ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH nKnown SUONS BSTANCE REMAINING Urikn wn GALLINERT MATERIAL 7 YES No THIS FORM HAS BEEN COMPLET D UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME RIG ho e _for Tri Star Hanes DATE IpRINT[pi SIGNATURE) Ik 5/21/}r� ---] LOCAL AGENCY USE ON[ THE STATE I.D.NUMBER IS C POSED OF THE FOUR NUMBERS BELOW STATE 1.D.# CmOUNTY x JURISDICTION R FACILITY iT TANK 1 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATX]N 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 CORM 9 (12-91) FORpQ,y14R{