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STATE OF CALIFORNWATER RESOURCES CONTR' BOARD FORM `B': UND'6GROUND STORAGE TANK PReRAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 4 FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARCO AM/PM Minimart, Facility 5650 FARM TANK-YES NO ❑X - 4 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 2 B. MANUFACTURED BY: Xerxes C. YEAR INSTALLED 1989 D. TANK CAPACITY IN GALLONS: 12,000 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. © 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. M UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL X❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF //�1 HAZARDOUS SUBSTANCE STORED 8 CAS # t CAS,#: /t/ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF © 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑X 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING F-] 3 EPDXY LINING F__] 4 PHENOLIC LINING LINING C. INTERIOR ❑ 5 GLASS LINING ®6 UNLINED [:]95 UNKNOWN LININ ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑X YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP M 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 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A&B 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. P 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTR NIC ITOR P 8 GROUND WAT R MONI OR G WELLS P CISION 6 PRETESTING P 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P OTHER e VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED D TE LAST USED(MO/YR) 2. ESTIMATED DUAN ITY OF 3, WA TANK FILLED WITH iv 16 1 SUBSTANCE ING IN MATERIAL' [:]YES ❑ NO GALLONSAV THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOIkLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATUR S} DATE Peter B. Tobin LvIGA / 4-24-89 LOCAL AGENCY USE ONLY CUNTY, ENCY## JURISDICTION# AGFACILITY ID# TANK IO# OP) IJl = = I d --,- 13 QO CURRENT LOCA ApENCY FACILIIYlIu(IID� APPROVED BY NAM PHONE#WITH AREA CODE PERMIT NUMBER 1. PERMIT APPROVAL DATE PdRMd EXPIRATION DATE \� CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT If BY: V FORM B(6-29-m) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AVr IT FORMA' HAS BEEN FILED DATA PROCESSING COPY