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STA i E C)E- C,ALIFUHNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDE' 'ROUND STORAGE TANK PRC IAM TANK TANK r `RMIT APPLICATION INFORMA. IION 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 rnA ONE ITEM ❑ 2 INTERIM PERMIT F]4 AMENDED PERMI1 ❑ 6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY A. OWNERS TANK ID # B. B. MANUFACTURED BY: Xerxes C. YEAR INSTALLED 19 90 D. TANK CAPACITY IN GALLONS: 10 , 000 11. TANK CONTENTS IF (.4.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. I A. EX] 1 MOTOR VEHICLE FUEL n 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT F-14 011. 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. 4 C.A.S. 9: I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF R�I 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 3 GRAVITY A U 91 NONE ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [:].95 UNKNOWN ❑ 99 OTHER U 2 STAINLESS STEEL 711 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED A ❑ 95 UNKNOWN A F4IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? `„ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 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 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 O 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 9) 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 U 8 100% 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 S 1 VISUAL CHECK P(p 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN (—P)S 99 OTHER Red Jacket PLD VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH N/A N /A GALLONS N /A SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. HPPLICAN NAME(PRI E &SI ATURE) Frances W. Hedric DATE Agent for ARCO S _5---) 0 rt; LOCAL AGENCY USE ONLY barghausen Consuiting Engineers, Inc. (916) 348 305 COUrnNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # l�J CURRENT LOCAL AGENCY FACILITY ID # r APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE !`uC!`Kk ocquir Aufl11NT TTCHARCEAur ."CC.,` BY. r FORS! B (6-29.,13) THIS FORM MUST BE ACCOMP,_._J BY A FACILITY/SITE APPLICATION, FORM 'A', UNLEa, A CURRENT FORMA' HAS BEEN FILED sAT,k PROCFSSING CCF`'