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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT ml S CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE O 9 TANK REMOVED OI <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ARCO Facility 5569 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS--SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.* Unkriawn S. MANUFACTURED BY: UTl]Q1CAVn x <br /> C. DATE INSTALLED(MO/DAY/YEAR) 88 D. TANK CAPACITY IN GALLONS: 12,000 <br /> II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL 4 OIL B. C. ® 1flUNLEAD D 3 DIESEL 6 AVIATIONGAS <br /> O 2 PETROLEUM O 80 EMPTY ® 1 PRODUCT1b PREMIUM 4 GASAHOL 7 METHANOL <br /> O UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT O 95 UNKNOWN � 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.s: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX D AND <br /> A. TYPE OF © / DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM O 2 SINGLE WALL O 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK O 1 BARE STEEL O 2 STAINLESS STEEL © 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F-1 5 CONCRETE 6 POLYVINYL CHLORIDE E:] 7 ALUMINUM O 6 100% METHANOL COMPATIBLE W/FRP <br /> (PdmeryTmk) 0 9 BRONZE ❑ 10 GALVANIZED STEEL [�] 95 UNKNOWN F-1 99 OTHER <br /> 0 1 RUBBER LINED O 2 ALKYD LINING O 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.ILILININGR O 5 GLASS LINING ® 6 UNLINED 95 UNKNOWN 0 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES XL NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP O 2 COATING 0 3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION ® 91 NONE O95 UNKNOWN F-1 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)95 OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)--95-- <br /> r IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A 4111 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL AS 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING <br /> A U 9 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL <br /> A U 10 CATHODIC PROTECTION A B 95 UNKNOWN A B 99 OTHER <br /> D. LEAK DETECTION ® 1 AUTOMATIC LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING Q 3 MONRORING Q 99 OTHER <br /> V.TANK LEAK DETECTION <br /> F7 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE O 0 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES O NO <br /> SUBSTANCE REMAINING GALLONS INERTMATERIAL7 <br /> THIS FORM HAS BEEN CO TED UNDER PE OF PERJ Y,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> --------- <br /> (PRINT D651GHATU E) <br /> Thomas Schoenstein 5/23195 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE LDA <br /> COUNTY# JURISDICTION# FACILITY# TANK# 00 <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FORM B (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 111,40, <br /> FORMIHIS <br />