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• c^��c. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B :ate b� COMPLETE A SEPARATE FORM FOR EACH TANK SYMM. MARK ONLY )m 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Q T PERMANENTLY CLOSED ON SITE ONE REM ® 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED OBAOR FACILT[YNAMEWHERETANKISINSTALLED: ARCO AM/PM Facility No. 6347, Tracy, CA 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.Y � B, MANUFACTURED BY: Xerxes C. DATE INSTALLED(MCtOAYtYW) 0. TANK CAPACITY IN GALLONS: 10,000/12,000 split IL TAMC CONTENTS IF A.1 IS MARKED.COMPLETE ITEM C, A ® 1 MOTOR VEHICLE FUEL E] 6 OIL B C 1.REGULA 2 PETROLEUM F7 80 EMPTY R UNLEADED Q 3 DIESEL 6 AVIATION GAS 1 PRODUCT 1D PREMIUM UNLEADED ram 4 GASAHOL 7 METHANOL ❑ 1c MOGAAOE UNLEADED 5 J£T FUEL 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 9S UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER(DESCRIBE IN rMA 0.BELOMQ D. IF(A.1)IS NOT MARKED. ENTER NAME Or-SUBSTANCE STORED C.A.S.it: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF I DOUBLE WAIL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ a SINGLE WALL IN A VAULT ❑ 99 OTHER S. TANK ❑ I BARE STEEL 2 STAINLESS STEEL ® 3 FIBERGLASS 4 STEEL CLAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 8RCNZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ i RUBBER LINED Q 2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ B UNLINED ❑ 95 UNKNOWN 99 OTHER FRP COATING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL YES-X mo— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ul 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION El CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN CD99 OTHER PILL CONTAINMENT INSTALLED(YEAR) E SPILL AND OVERFILL,9iC. OVERFILL P £VENTION EQUIPMENT INSTALLED(YEAR} - DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTANMENT YES NO IV.PIPING INFORMATION CIRCLE A IF A80VE GROUND OR U IF UNOERGROUNO.BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U t SINGLE WALL AoZ 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 04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U J STEEL WI COATING A U 6 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 N5L7uWCAl yNt¢LFru H-�H 2 ung TIG^04 (�3 CONnnuaus KMUVMl a EL "owc of �7 5=PUMP ❑ 99 OTHER D. LEAK DETECTION ® t1gTEGTDR l� TesaKa; 1� MOWTo5 ❑ ti�4tc oErgcrort o 91+utiROww V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ Z RECONCILIATION ONORY ❑ 3 MONITORING ORING ❑ 4 GAUGING AUTOMATIC TANK ❑ 5 GROUND MONITORING AITER ❑b TESTINGTANK ® 7 CONTINUOUS INTERSTITIAL a a SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER MONITORING TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2 ESTIMATED QUANTITY OP 3.WAS TANK FILLED WITH YES a NOE] SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS SEEN COMPL MD UNDER PENAL TY OF PERJURY,ANO To THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME /� DATE (PiRINTE04 SIGNATURE) '�--y / C3 f LOCAL. AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY B JURISDICTION s FACILITY 4 TANK Y op STATE I.D.4 1 3 j I o I 10 PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THUS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WaN THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95) 0 6 -d WAodA WdZZ= 1 L661-60-L