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9 • STATE OF CALIFORNIA J STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ^^❑ 6 TEMPORARY TANK CLOSURE ii 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: LEI- S A IJ. I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN U44 If- 0. OWNERS TANK L D.a {�L'I, B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) U(.(1,__ I D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. 13 REGULAR UNLEADED�3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1b PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ i PRODUCT ❑ Ic MIDGRADE UNLEADED ❑ 5 JETFUEL ❑ 8 MSS E] 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 �ppEp ❑ gg OTHER(DESCRIBE IN fTEM O.BELOW D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.4 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I 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 W/FRP (Primary Teak) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ,}❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING yI 8 UNUNED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100°A METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION81 NONE ❑95 UNKNOWN ❑ 99 OHER PROTECTION ❑ s cAHoolc PROTECTION SPILL CONTAINMENT INSTALLED(YEAR) OVEflFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP YES_ NO__ STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION Ato 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND ACV 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 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 85 UNKNOWN A U 99 OTHER 1 ❑MEGMMGL UNE IFAK 2 UK MIlIKSS ❑3 CwjI S WfEASrmAL 4 RE7M0MC UK 5 AM MAIC NAR ❑ 99 OTHER D. LEAK DETECTION ❑ �=A ❑ TEsnNG uaaronlMl ❑ SAK MW 9ARODWN V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONORY ❑ 3 MONITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONTORINGOUND WATER ❑6 ANNUALTESTING E] 7 COMON INUOLG ORININTERSTITIAL ❑ 8 SIR E:] 9 TANK LY MANUAL ❑10 MO TTHL TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE VA LAST USED(MO/OAY/YR) 2. SUBEST' TED OU REMAININGANn F ZS GALLONS 3 WA VERT MATERIAL 7STANKFILUED TH YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PEN OF PE RY,A TO THE BEST OF MY KN WLEDGE, lS TRUE AND C RECT TANK OWNERS NAME 1 , 1 ' (PRINTED 8 SIGNATURE) (/ k LOCAL AGENCY USE ONLY THESTATEI.D. MB IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY M JURISDICTION NFACILITY l# TA� STATE I.D.A m = PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT E%PIRATION UATE MUST BE COMPLETED FOR THIS FORM MUSTORM A,UNLESS A CURRENT FORM A HAS BEEN FILE SHOULD BE ACCOMPANIED BY AIP OT FILE FTHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING ERGR UND STORAGE TA K REGULATIONSNS. THIS FORM FORMS (6-95)