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STATE OF CAUFO A +' • c, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APLICATION - FORM B COMPLETE A SEPARATE FORD FOREACH TANK SYSTEM. MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDEO PERMIT ❑ TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY.NAME WHERE TANK IS INSTALLED: Tri Star Homes I. TANK DESCRIPTION COMPLETE ALL ITEMS-• SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.a linknown B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) Unknown D. TANK CAPACITY IN GALLONS; a7 800 longs II.TANK CONTENTS IF A•1 IS MARKED,COMPLETE ITEM C. V L REGULAR A. 7 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1aUNLEADED 3 DIESEL I--] 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY i ❑ 1 PRODUCT ❑ 1bIUM ❑ 5 JET FOOL ❑7 METHANOL UNLEADED ❑,l 3:CHEMICAL PRODUCT ❑ 95 UNKNOWN O 2 WASTE a 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. 1F(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 ALLTHAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM M 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT AULTED TANK) ❑ 99 OTHER �► B. TANK 1 BARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W1 FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 13RONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOP ❑ 5 GLASS LINING Fv7 6 UNLINED ❑ 9 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WfTH 100%METHANOL? YES NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED_ PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION K] 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) none OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)__pone IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 99 OTHER B. CONSTRUCTION A l SINGLE WALL A U 2 DOUBLE WALL A U LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C.--MATERIAL AND A 1 BARE STEEL A U 2 STAINLESS STEEL A U POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U STEEL W1 COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99. OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 RTER TITIA I ❑ 99 OTHE R none V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITOR) G ❑ 4 AUTOMATIC TANK GAUGING F-] 5 GROUNDWATER MONITORING ❑ 6 TANK TEST4NG 7 iNTERSTITIALMONiTORING ® 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMAITEOiDATE_LAST USED(MO/DAVlV R) 2 ESTIMATED SUBSTANCCEQUANTITY REMAINING own 3.WAS ) H VES GALLONS INERT MATERIAL? NO THIS FORM HAS BEEN COMPLE D UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT APPLICANTS NAME IC 1 or i rl mea DATI�- (] (PRINTED a SIGNATURE) '/2 q I,y7 LOCAL AGENCY USE ONL THE STATE I.D.NUMBER IS C POSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY#- TANK# STATE I.Q.# m ❑ .-'' —� PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESSA CURRENT FORMA HAS BEEN FILED. FILE THIS FORM W�E LOCAL AGENCY IMPLEMENTING THE UNDERGROUNQRAGE TANK REGULATIONS FORM B (12.91y FORD04645 r