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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a m� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Si E OF INFORMATION ❑ 7 PERMANENTLY CLOS 'ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT TEMPORARY TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ARCO lac 61-bs 0 Iti I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN 0. OWNER'S TANK I.D.t - B. MANUFACTURED BY: XeR'Ae S C. DATE INSTA�LrLrEeD(MODAYNFAR) 3 1 g D. TANK CAPACITY IN GALLONS: l Q C� 0 11.TANK CONTENTS ENT.S IF A-1 IS MARKED.COMPLETE REM C. A Z 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. to REGULAR UNLFADED ❑ 3 DIESEL ❑ 6 AVIATION GAS F72 PETROLEUM ❑ 80 EMPTY 2-1 PRODUCT 1b PREIAIM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL 1a WOGROE UNLEADED 5 JETFUEL ❑ 9 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER MOMS IN REM D.BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.8: III. TANK CONS�T�RTUCTION MARK ONE ITEM ONLY IN BOXES A,8,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ,ILY, I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL �Er 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (r^MY Twk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING OR ❑ 5 GLASS LIVING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION - PROTECTION ❑ 5 CATMODICPROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PR EVENTION EQUIPMENT INSTALLED(YEAR) DROPTUSE VES V NO_ STRIKER PLATE VES_ NO_ DISPENSER CONTAINMENT YES_ NO_ IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IFAPPUCABLE A SYSTEM TYPE A U I SUCTION AW2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U W OTHER B. CONSTRUCTION A U / SINGLE WALL ACU 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 I�r cu vI�A�c E]2 �� ®3�wrearntut 7-1 4¢r:cmc«cc s�nc nAc 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATIONINVENTORY. 3 MONITORING ADOZE ❑ 4 G`UGINGC TANK E] 5 MONITORINGGROUND ❑ 6 MNUALTESTING 7 MONRORIG NTERSTTT1AL ❑ B SIR ❑ 9 TVPhEXL AUGING� E:]10 ONTHGY TANK E] 95 UNKNOWN ❑ 99 OTHER TESTIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED WIDAYNS) 2 ESTIMATED QUANTITY OF 3.WAS TANK FII I Ffl WITH VES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND T07NE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK (PRH5TEDATwQ NAME J1�_.. . DATE 3II-TI J LOCAL AGENCY USE ONLY THE STATE LD.NUMB IS COMPOSED OF THE FOUR NUMBERS B W COUNTY 0 JURISDICTION k FACIUTY k ' TANK K STATE LD:# m = v . : � - 3 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE W- e THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. MUST BE COMPLETED FOR INSTALLATIONS.(THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PWLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH GROUND STORAGE TANK REGULATIONS FORM B (6-95)