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STATE OF CALIFORNI WATER RESOURCES CONTRC' 90ARD FORM B': UNDEWGROUND STORAGE TANK PROGRAM i `± TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK 18 INSTALLED: Q 3 e.� ,LIU FARM TANK-YES❑ NO - Z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID N [,�/kf B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: / 0000 w 11. TANK CONTENTS IF(A.l),IS MARKED,COMPLETE ITEM C.IF(A.l),IS NOT MARKED,C MPLETE ITEM D. A. 1 OR VEHICLE FUEL F-] 2 PETROLEUM B. G. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL �PBODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CAS.R C.A.S.N: ' I All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH DMOR UNER ❑95 UNKNOWN SYSTEM { 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER Ei<MB/IRON ❑2 STAINLESS STEEL ❑3 RBERGUM ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MMATERIALF-15 CONCBLTE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8109%METHANOL COMPATIBLE FRP ❑9 f9i0N2E ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER I C. INTERIOR r-11 RUBBER UfED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC UNING 1 LINING ❑5 GLASS LINING ❑6 UNLINED Fa%UNKNOWN [-] IS UMNG MATERIAL COMPATIBLE WITH 1011%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 PDLYED%EW WRAP ❑2 TARORASPHALT ❑n"95 K/3 VINYL WRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE Irl 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U T SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER R. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH Ao 95 UNKNOWN A U 99 OTHER A U / STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 F18ERGLASSPIPE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLAOW/FRP A U 8 IOD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A©U 95 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. S P 8 1 VISUAL CHECK O S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS DTY P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P ag 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 PA SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO A (THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID N m = = 1 I�7) c I l sFF / aC) 0l CURRENT LOCAL AGENCY FACILITY IDA APPROVED BY NAME PHONE k WITH AREA CODE DG Ko PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: mmmmo FORM B(3a-Tia) THIS FORM MUST DE ACCOMPANIEEDY AFACILITY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORMA' HAS BEEN FILED :OCESSING COPY