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STATE OF CALIFORK . WATER RESOURCES CONTRC /OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM - �`- TANK TANK PERMIT APPLICATION I ORMATIONo COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY 59 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSAD TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED Ov FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARCO Facility >/6020 FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A OWNERS TANK IDN 2 B. MANUFACTURED BY: Xerxes C. YEAR INSTALLED I qA D TANK CAPACITY IN GALLONS 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A D 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED E32 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&C A S N C.A.S N. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,i D A.TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR 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 8.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-] 1 RUBBER LINED ❑2 ALKYD LINING El3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 10011 METHANOLS YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCE 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 8. CONSTRUCTION A U I SINGLE WALLED An 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 U 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 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 CINRCVLEEDL.. P f 1 VISUAL CHECK P T 2 INVENTORY RECONCILIATION P f 3 VADOSE WELLS ELECTRONIC MONITOR ► { 5 GROUNQ-WeR MaC eLG YLll P f 6 PRECISION TESTING P f 7 PRESSURE TESTING P f 91 NONE P { 95 UNKNOWN n{ 99 OTHER 1tCC J VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED OUANTITY OF3 WAS TANK FILLED WITH N/A SUBSTANCE REMAINING IN N/A INERT MATERIAL)N/A OYES ❑ NO GALLONf THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTNAME(PRIN ED b IGNATURE) DATE Frances W Hedrick 10-4-90 LOCAL AGENCY USE ONLY Barghausen Consulting Engineers, Inc. (916) 348-3057 COUNTY N JURISDICTION N AGENCY f FACILITY 10 f TANK ID N CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE•WITH AREA CODE 7C 5 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 1 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT {Y: FOAM B(6-29-68) THIS FORM MUST K ACCOWP ' "1 BY A FAurTY/VIT APPMTWK FORM'A',UNLESS A-40M FOW'A' IMS BEEN FILED 1 DAI IOCESSING COPY 2 VOCAL AGENCY COG 3 F LE COPY