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STATE OF CALIFOR? l WATER RESOURCES CONTRI IOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TAMC TANK PERMIT APPLICATION I ORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARCO Facility # 6020 FARM TANK-YES❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A OWNERS TANK ID N 1 B. MANUFACTURED BY: Xerxes C. YEAR INSTALLED 19 91 1 D TANK CAPACITY IN GALLONS: 10,000 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),18 NOT MARKED,C MPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8, C. IM 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 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 6 C A S.N C A.S N. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A. TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH DTE"LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ®3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM F18 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-] I RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C. LIN NG R ❑5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOLI ®YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 8. CONSTRUCTION A U 1 SINGLE WALLED A 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 O 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL C[-ADW/FRP A U 8 1OD%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( 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 1-: 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WE P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P f 91 NONE P S 95 UNKNOWN S 99 OTHER Red JacketSL VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED QUANTITY Of3 WAS TANK FILLED WITH N/A SUBSTANCE REMAINING IN N/A gALLONt INERT MATERIAL N/A E-1YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLI NTS NAMEPRINT D SIGNATURE). DATE y Frances W. Hedrick -/. Agent for ARCO 10-4-90 LOCAL AGENCY USE ONLY Barghausen Consulting Engineers, Inc. (916) 348-3057 Fu - PERMIT JURISDICTION S AGENCY N FACILITY ID R TANK ID S � �� 5 - o c)I c I IGENCY FACILITY ID 0 APPROVED BY NAME PHONE t WITH AREA CODE NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 6 BY: _ C A' FORM a(6-29-66) THIS FORM MUST K A=W' -1 n'A FACJLmwm AppLcATwK FORM'A',UNLESS A"4110W FM'A' NAI KEN FILED 1 DA- AOCESSING COPY 2 LOCAL AGENCY Co, 3 t"LE COPY