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'sba�.cea STATE OF CALIFORNIA ,a"•• ` STATE WATER RESOURCES CONTROL BOARD Wye a a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM Q 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE fes( 8 TANK REMOVED/`` DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Trinrnpq [ gyp( ct' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.0.a Unknown B. JANUFACTURED BY: Unknown C. DATE INSTALLED(MOCAYNEAR) UnknoWn 0. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B- C ❑ to REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 89 EMPTY ® 1 PRODUC ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOI ❑ 7 METHANOL 1e MOGRADE UNLEADED F__15 JET FUEL 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ z WASTE ® 2 LEADED ❑ 99 DIRER{DESCRIBE w IFEm D.BELOW) 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 NTEgNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ® 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W!FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ TO GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING B UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES NO— D'EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 5 UNKNOWN ❑ 99 OTHER E gam, SPILL CONTAINMENT INSTALLED(YEAR) OV RFI LL PREVENTION EQUIPMENT INSTALLED(YEAR) SPILL AND OVERFILL, DRCP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNDERGRO D,BOTH IF APPLICABLE A. SYSTEM TYPE A t 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A (nD 1 SINGLE WALL A U Z DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A W 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 6 CONCRETE A U 7 STEEL W!COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 19 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION1 uE0"G1L LmE LEAK ❑2 uNE 1wwwss E:l 3 COrrnNUOUS i 4 ELECTROMC UNE 5 AUTOMATIC PUMP Q� ❑ DETECTOR TESTING YONITORWG LEAK DETECTOR ❑ gfJTDD MN ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONINVENTORY ❑ 3 VAEMONITORING ❑ 4 GAUGING AUTOMATIC TANK C:] 5 MRONITORING� OUND R ANNUALTANK ❑ B TESTING ❑ 7 MON TORIOU INTERSTITIAL ❑ 8 SIR ❑ 9 CNK GAM AN AL ❑ 10 M SNTHLL}Y TANK ® 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED f A8� SED(MO/DAYIYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO `ltfk++vv'"i SUBSTANCE REMAINING nknownGALLONS INERTMATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER ENALTY OF PERJURY,A TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME(PRINTEO&SIGNATURE} d Th r ent for Tri Star Homes, LLC DATE 5/21/97 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS C116POSED OF THE OUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK it 11 1 STATE LD:# mEF I PERMIT NUMBER PERMIT APPROVED BYIOATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FOR 4 A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN- FILE THIS FORM WITH THE LOCAL AGICY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6.95)