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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B 1 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ED3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED ON SITE ❑ ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ® B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: W ESS k.6 11 L "Poo 16�01 LCLOA- 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.X 3 I S. MANUFACTURED BY: UNILI.IOoAI C. DATE INSTALLED(MC/DAY/YEAR) D. TANK CAPACITY IN GALLONS: !J. ILTANK CONTENTS IFA-11S MARKED,COMPLETE ITEM C. 1 M ❑ 4 OIL B. C. ❑ 1. REGULAR UNLEADED ❑ 3 DIESEL ❑ 8 AVIATION GAS MOTOR VEHICLE FUEL A ❑ lb PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1,MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN TEM D.BELOW)) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED IIA C.A.S.X: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND A. TYPE OF F-11 DOUBLE WALL F-13 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ® 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PriMWY Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING C.INTERIOR LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED © 95 UNKNOWN ❑ 99 OTHER COATING IS UNING MATERIAL COMPATIBLE WITH 100°.6 METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSIONgl NONE ®95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ SPILL CONTAINMENT INSTALLED(YEAR)1.M4Meu N OVERFILL PREVENTION EQUIPMENT INSTALLED(VEAR)NN1r_JOW J E.SPILL AND OVERFILL,CTO. DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES_ NO__ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCA13LE A. SYSTEM TYPE A U 1 SUCTION A® 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH AQ 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 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 B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER / M"C MO'R L LME IFNI 2 IME iK1n1E5a ❑3 CWRMVWa MIFIMTiLOL ❑A EIECIPONIC LXX: ❑5 AUfOLMTIG PBLP ©99 OTHER�e VlQ0 J D. LEAK DETECTION ❑ OETECTng ❑ 1Emxa uoNraBXK+ 1TAIC DETECTOR 9a1100WX V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RORY ❑ 3 ❑ 4DC TANK TER ❑6 ANNUALTANK RECONCILIATION MONITORING GAUGING MONITORING TESTING ❑ 7 CON INUOU INTERSTITIAL ❑ B SIR ❑ 9 WEEKKLLYY MANUAL E]10 MONTHLY TANK ® 95 UNKNOWN ❑ 99 OTHER TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST Uf(MOIDAYINR)L4ES"nMATED BSTAN MAITY OF GALLONS 3 WAIN N MATERIAL K FILLED 7HYES ® NO❑ THIS FORM HAS BEJU Y, /T.00 T�HE�BES/T�OF MY KNOWLEDGE,IS TRUE AND CORRECT NA r.1-I TAIL DAT ER LOCAL AGENCY USE ONLY THE STATE I.D. OSED OF THE FOUR NUMBERS BELOW COUNTY# JU SDICTION p FACILITY]= TA� STATE I.D:# m PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE M C MUST BE THIS FORM MUSTSHOULD BE ACCOMPANIED BY A BPERMIT PLO�n FILE THIS FORM WITH THE LOCAL AGENCY MPLEMENTINGRENT FORM A HAS BEEN IWDE GROUND STORAGEETANKRREGULATIONSNS.THIS FORM FORM B (6-95)