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STATE OF CALIFORN6 4 WATER RESOURCES CONTI BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION mom' a COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 'A•Y• MONS ARK OEMY6) ❑2 IN7E PERMIIIM RMIT ❑4 AMENDEDPERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY/C�L)pSEO TANK ❑ ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE 3W �f',�- FACILITY/SITE NAME WHERE TANK IS INSTALLED 3 / FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O A. OWNERS TANK ID q 4 4 Q 1, oVC1 B. MANUFACTURED BY: C. YEAR INSTALLED i- D. TANK CAPACITY IN GALLONS: Lfo W 11, TANK COtATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. � Q A MOTOR VEHICLE FUEL ❑2 PETROLEUMB. �,,,,yyyrrr,,,JIIIIII—�I�I�I� 1 UNLEADED LEADED ❑ 3 DIESEL ( ( ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT (✓�J 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5*t1AZARDOUS ❑80 EMPTY 9�95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF OT MOTOR VEHICLE FUEL,ENTER NAME OF n HAZARDOUS SUBSTANCE STORED&C.A.S.# /Ti j�- C.A.S.#: KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.a D A.TYPE OFOV ❑ 1 DOUBLE WALLED ❑3SINGLE WALLED WITH EXTERIOR LINER UNKNOWN (' SYSTEM '/ ❑2 SINGLE WALLED ❑ 4'SECONDARY CONTAINMENT ❑99 OTHER .3,' /�' ❑ I STEEURON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALU M ❑8 IOD%METHANOL COMPATIBLE FRP IRF ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C �� 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHE CUNING I LINING 5 GLASS LINING ❑6 UNWNED 7 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WFFH,I00%METHANOL �/ YES ER D. CORROSIO 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VIN%L, ❑99 OTHERWRAP ❑4 FIBERGLASS REINFORCED PLASTIC - PROTECTI E]5 CATHODIC PROTECTION ❑91 NONE rZjASU/NKNOWN ❑99 OTHER IV. PIPING INFORMATLON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U UCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTIO(V A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEELCLADW/FRP A U B 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Ac"UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ?� P 5 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2, ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH M yl ,///j SUBSTANCE REMAINING IN INERT MATERIAL? []YES ❑ NO i v GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY OUNTY# JURISDICTION# AGENCY# FACILITY ID# Q TANK ID# 3 ( 2, �t 3 U I U U R LOCAL AGENCY FACILITY ID# V Y E �� PHONE#WITH AREA COOS poIV 30 PERMIT NUMBER I P~/ APPROV DA PERMIT ATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-ee) THIS FORM MUST BE ACCOMPANIED-.A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A c ePIENT FORMA' HAS BEEN FILED DATA PROCESSk