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STATE OF CALIFORNIA °s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM- MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENCED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK ISINSTALLED: ARCO AM/PM Facility No. 6347, Tracy, CA 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D.A B. MANUFACTURED BY: Xerxes C. DATE INSTALLED(MC/OAa;NEAR) Gf 0. TANK CAPACITY IN GALLONS: 10,000, IL TANK CONTENTS IF A.1 IS MARKED.COMPLETE ITEM C- A. A 1 MOTOR VEHICLE FUEL ❑ A OIL BC I to REGULAR UNLEADED 3 DIESEL 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 60 EMPTY T PRODUCT f Sp P96MAIM UNLFADED U A GASAHCL 7 METHANOL IQ MWAADE UNLEAC£0 r{ S JET FUEL 8 M86 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE Q 2 LEADED 99 OTHER(DESCRIBE IN rMA 0.SEC" D. 1F(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.e: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.&AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LWSR ❑ s INT-RNAI.BLADDER SYSTEM Q 45 uNKNoWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHO B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ a STEEL CLAO W!FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 8 POLYVINYL CHLORIDE 7 ALUMINUM $ 100: METHANOL COMPATIBLE W~ (Prnnary Tank) ❑ 9 BRCNZE ❑ 10 GALVANIZED S F-L ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYO LINING 3 EPDXY LINING ❑ A PHENOLIC LINING LINING OR ❑ S GLASS LINING ❑ 6 UNLINED 95 UNI01OWN 99 OTHER FRP COATING IS UNING MATERIAL COMPATIBLE WITH 100 METHANOL? YES-�< NO— D.SMRIOA ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATkC01C PROT(CION ❑ 91 ONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL P4EVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IFAGOVEGRCUNOOR U IFUNOERGROUNO.80T14tFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A(pZ DOUBLE WAU. 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(9)s FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 8 CONCRETE A U 7 STI.'-N W/COATING A U 8 ICED% METHANOL COMPATIBLE WNFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CAT)IOOICPRCTECMON A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 4CK04M UK LEAKI�2 vt+6 nGmYW-1s ELS 3 cowralt aA xr SMS �a agcm*c UI+E 0 S �PUW �,� o� pETECtOR l�`'1 �,1INa J9 WONTC04 m"OMCMA V.TANK LEAK DETECTION 71 1 VISUAL CHECK ❑ 2 REEC NMANUNL•UATIION � 3 MONITTORING A GAUGING AUTOMATIC TANK ❑5 MONITORING WOUND WATER 0 6 ANNUAL TESTING sz 7 :MON TQR NG INTERSTITIAL Q 9 SIR Cl9 WEEKLYTANKA UGING MANUAL E!!10 MONTesTHLY TANK ❑ 95 UNKNOWN a 99 OTHER VI.TANK CLOSURE INFORMATION(PemmmfiNT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOADAYNR) 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES Q NO❑ SUBSTANCE REMAINING GALLONS+ INERT MATERIAL 7 THIS FORM HAS BEEN COMPLgW UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNES'S NAME DATE (PAINTED d SIGNATURE1y� 1/ C LOCAL AGENCY USI: ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION tr FACILITY a 1 C9(0 TANK STATE 1.0: M0 T-1 (0 0 PERMIT NUMBEA I PERMIT APPROVED SYMATE PERMIT EXPtRAT[ON DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST HE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY MPLEMEN71MG THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (6-95) 0 E 'd . . ►^IOJd WdZZ: l L66 L—6©—L