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STATE OF CALIFORNIA,; WATER RESOURCES'CONTROLARD o" FORM V: UNDERGROUND STORAGE TANK PROG M .mom TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY im1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 712 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED F110 n FACILFTY/SITE NAME WHERE TANK IS INSTALLED: ARCO AM/PM Ninimart - Facility # FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID R NO. 3 B. MANUFACTURED BY: Xerxes C.YEAR INSTALLED 1988 D. TANK CAPACITY IN GALLONS: 12,000 N 11. TANK CONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. {X 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. [::] I UNLEADED ® 2 LEADED ❑ 3 DIESEL W ❑3 CHEMICAL PRODUCT ❑ 4 OIL ® 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS - ❑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.R CAS.N: xIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D A. TYPE OF EZL7 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWALIED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS SjFB. [jJ3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 810D%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNI NG LINING ❑5 GLASS LINING ❑6 UNUNED ❑X 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER 0. CORROSION ❑ 1 POLYEIHLENEWRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP ®4 FIBERGLASS REINFORCED PLASTIC 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 A U PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A nFIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FAP A 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. s✓ P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS 0 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �(nl P S 6 PRECISION TESTING PS 7 PRESSURE TESTING 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? ❑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 B SIGNATURE DATE P. B. Tobin LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY N' FACILITY ID R TANK IO M aRl F= 16114:3L- 13131-71 ID101c) [31 CURRENT LOCAL AGENCY FACILITY ID N APPRO ED Y NAME PHONE N WITH AREA CODE D PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIIIIATION DATE CNECKN PERMITAMOUNT SURCHARGEAMT. FEE CODE CEIPTN BY: FORM B(3-7-86) THIS FORM MUST BE ACCOMPANIEL�ACILITY/SITE APPLICATION, FORM 'A',UNLESS r FORMA' HAS BEEN FILED -!90CESSING COPY 4: