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STATE OF CALIFORNIA WATER RESOURCES CONTROL P HARD FORM V: UNDERGROUND STORAGE TANK PROGmAM m TANK TANK PERMIT APPLICATION INFORMATION ,, COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY AO NEW PERMIT ❑3 RENEWAL PERMIT 0-k CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 1:1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARCO AM/PM M11timart — Facility # FARM TANK-YES NO ® z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I© A. OWNERS TANK ID# No. 2 B. MANUFACTURED BY: Xerxes C. YEAR INSTALLED 198$ D. TANK CAPACITY IN GALLONS: 12 N 000 A 11. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 00 A. ® 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM BC. ® I UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ® 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY F] 95 UNKNOWN ID2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# GAS.W XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 D A. TYPE OF ® 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAUFD ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ®3 FIBERGLASS ❑ 4 STEEL GLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑70 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED [—]2 ALKYDUNING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ® 95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METMANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP ® 4 F18ERGLSS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑%UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A 713 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A N2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A C4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S I VADOSE WELLS4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P 7 PRESSURE TESTING P S 91 NONE- S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATEDGUANTITYOP 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ 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 8 SIGNATURE DATE P. B. Tobin LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID• APPR VE BY NA E PHONE#WITH AREA CODE �Q T PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANlt%Z CILITY/SITE APPLICATION, FORM'A',UNLESS; r 111911t FORMA' HAS BEEN FILED J DATA PROCESSING COPY �