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STATE OF CALIFORNIA WATER RESOURCES CONTROL PnARD FORM 'B': UNDERGROUND STORAGE TANK PROGr-rAM a TANK TANK PERMIT APPLICATION INFORMATION ` �CCOMMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ANEW PERMIT ❑3 RENEWAL PERMIT 5CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSEOTAN ONE ITEM F--] 2 INTERIM PERMIT F-14 AMENDEDPERMIT 616 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED IN FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARCO AM/PM MinimaTt - Facility # FARM TANK-YES❑ NO ® l I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O A. OWNERS TANK ID# NO. 1 B. MANUFACTURED BY: Xerxes C. YEAR INSTALLED 1988 D. TANK CAPACITY IN GALLONS: 12,000 N II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ul A. ® 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. © 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL X❑ i PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS v ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A.TYPE OF ® i DOUBLE WALLED ❑3 SINGLE WALLED WITH EXIENIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ®3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%MEIHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED E]2 ALKYD LINING F-13 EPDXY LINING F-] 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ® 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP '❑2 TAR OR ASPHALT ❑3 VINYL WRAP ®4 FIBERGLASSREINFORCEDPLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION p 02 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A to 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A 0 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%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. _f P 8 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS(!)S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTI NG P S 91 NONE P 8 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE P. B. TobinG LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o '�' 3 3 0 1C) 10 1 / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BYA M PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE / PERMIT EXPIRATION DATE CHECK# MRMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIbmfflPWACILITY/SRE APPLICATION, FORM 'A',UNLES FORMA' HAS BEEN FILED DATA PROCESSING COPY