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STATE OF CALIFORNIf,J WATER RESOURCES CONTRO( ?ARD ' <br /> FORM `B': <br /> UNDERGROUND STORAGE TANK PROGRAM %m <br /> TANK PERMIT APPLICATION INFORMATION TANK. o., <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH <br /> TANK _ u I <br /> MARK ONLY [� <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TAN <br /> ONE ITEM El INTERIM PERMIT � 4 AMENDED PERMIT � 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED I w <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARCO AM/PM MinimaTt> Facility #5650 FARM TANK-YES❑ NO Q <br /> N <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY co <br /> A. OWNERS TANK ID# 3 B. MANUFACTURED BY: Xerxes <br /> C. YEAR INSTALLED 1989 D. TANK CAPACITY IN GALLONS: 12>000 <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> B C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> A. © 1 MOTOR VEHICLE FUEL � 2 PETROLEUM ©1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> E] 3 CHEMICAL PRODUCT �4 OIL <br /> 5 HAZARDOUS BO EMPTY 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF GAS.IF <br /> HAZARDOUS SUBSTANCE STORED&GAS.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D <br /> X t DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> A TYPE OF 0 99 OTHER <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT <br /> 1 STEELIIRON ❑ 2 SUINLESSSTEEL 0 3 FIBERGLASS � 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F-1 5 CONCRETE 6 POLYVINYLCHLORIDE ❑7 ALUMINUM 8100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL 0 95 UNKNOWN ❑99 OTHER <br /> 1 RUBBER LINED F-1 2 ALKYD LINING 0 3 EPDXY LINING 4 PHENOLIC UNING <br /> C.INTERIOR5 GLSS UNING ❑X 6 UNUNEO 95 UNKNOWN <br /> LINING <br /> IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ®YES [:] NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP F-1 2TAR OR ASPHALT F-] 3VINYLWRAP F�4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> 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 <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINVLCHLORIDE(PVC) A FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 10M METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A SRIMtRY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 1VISUAL CHECK P 21 NVENTORYRECONCILIATION P 8 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5GROUND WATERM LORI GWELLS <br /> P 6 PRECISION TESTING P 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 1099 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED JATE LAST USED(MO/YR) 2. ESTIMATED UANTITY OF 3.WAS ANK FILLED WITH <br /> SUBST IN MAINING IN GALLONS TERIAL? E]YES 0 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL DGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) KQ - DATE <br /> Peter B. TobinI. 4 fib/ 4-24-89 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 1010 10131_ <br /> CURRENT LOc'RL ENCY FACI{.LTY I APPROVED BY NAM PHONE N WITH AREA CODE <br /> !_ r/s` IJY I a,07 <br /> PERMITNUMBER PERMIT APPROVALOATE PE MIT XPIRA ION DATE <br /> CHECK# PERMIT AMOUNT >SURCHARGE AMT. FEE CODE ` REECEIPT# BY: <br /> FORM B(6-29-&B) T141B FORM MUST BE AC IOMPANIE Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS AIT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY _ <br />