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STATE OFCAUFORMA <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 I NEW PERMIT E] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE R 7 PERMANENTLY d.0 ON EM O 2 INTERIM PERMIT � a AMENDED PERMMIIT � 8 TEMPORARY TANK CLOSURE � 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ARCO V-*. <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.t \ B. MANUFACTURED BY: 1(_ <br /> C. DATE INSTALLED(MOMAYNEAR) -\1 D. TANK CAPACITY IN GALLONS: ` <br /> II.TANK CONTENTS IFA-11SMARKED.COMPLETE ITEM C. <br /> A. 1 MOTOR VEHICLE FUEL A OIL S, C IRREGULAR 3 DIESEL a AVIATION GAS <br /> UNLEADED A OASE <br /> 2 PETROLEUM a 0p EMPTY ® 1 PRODLIOT O IO PREMIUM 7 METHANOL <br /> 3 CHEMICALPRODUCT ED 95 UNKNOWN 2 WASTE UNLEADED ❑ 5 JET FUEL <br /> 2 LEADED o 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S. <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLES IN BOX O ANDS <br /> A. TYPE OF ❑ 1 DOUBLE WALL a 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ® 2 SINGLE WALL El A SECONDARY CONTAINMENT (VAULTED TANK) O W OTHER <br /> S. TANK ❑ I BARE STEEL E] 2 STAINLESS STEEL ® 3 FIBERGLASS a STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE 8 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE NFRP <br /> (kmwyTW) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN F--j 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LMMG 3 EPDXY LINING A PHENOLIC LINING <br /> LINING ® <br /> C.INTERIOR 5 GLASS LINING 8 UNLINED <br /> LINING � 95 UNKNOWN Do OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL i YES— NO_ <br /> D.CORROSION O I POLYETHYLENE WRAP 2 COATING 3 VINYL WRAP A FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EGUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> S. CONSTRUCTION Alli 1 SMGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U B CONCRETE A V 7 STEELW/COATING A U 8 100% METHANOL COMPATIBLENFRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER A� <br /> 0. LEAK DETECTION ® 1 AUTOMATIC LINE LEAK DETECTOR ® 2 LINE TIGHTNESS TESTING MONROiiING ❑ 90 OTHER x% <br /> V.TANK LEAK DETECTION <br /> 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION E 3 VADOZE MONITORING A AUTOMATIC TANK GAUGING O S GROUND WATER MONITORING <br /> B TANK TESTING O 7 INTERSTITMLMONITORING = 91 NONE 95 UNKNOWN a 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAS Tj� ED( ATPIA) 2.ESTIMATED QUANTITY OF g 3.WAS TANK FILLED WITH YES NO <br /> `t 'L\��} SUBSTANCE REMAINING '"'p' GALLONS INERT MATERIALi <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> IPAPPLICANTSRIKIE9A NAME <br /> S_ATUREI DATE <br /> \� <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMB RS BE 4Y <br /> COUNTY x JURISDICTION x FACIL x TANK x <br /> STATE I.D.# -3 —I 6 <br /> 1 A 141 <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> 9 6 <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS WN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE T'NK REGULATIONS <br /> FORMS (12.91) ROMOMN <br />