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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ED 8 TANK REMOVED DBAOR FACILITY NAME WHERE TANK IS INSTALLED: CHEVRON SERVICE STATION 301 U. KETTLEMAN LANE, E ;lf)T I. TANK DESCRIPTION COMPLETE ALL ITEMS – SPECIFY IF UNKNOWN A OWNER'S TANK I. D. # B. MANUFACTURED BY: X E R X E S C. DATE INSTALLED (MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: 10,000 II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JETFUEL E] 8 M85 E]3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL E( 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D. EXTERIOR ❑ 1 POLYETHYLENE WRAP F] 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL, etc. SPILL CONTAINMENT INSTALLED (YEAR) ' "" "''" ' OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A7095 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 5 ALUMINUM A U 6 CONCRETE A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP 5-7*5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ DETECTOR TIGHTNESS0 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE 5 AUTOMATIC PUMP ❑ TESTING MONITORING ❑ LEAK DETECTOR ❑ SHUTDOWN ❑ 99 OTHER V. TANK LEAK DETECTION ❑GROUND WANUAL 1 VISUAL CHECK ❑ 2 RECONCILIATION ORY ❑ 3 MONITORING ❑ VADOZE4 GAUGING AUTOMATIC TANK ❑ 5 MON TORINGTER ❑ 6 TESTINGTANK ❑ 7 CONMON INUO US G INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL [:]10 MONTINGY TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/OAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING T:GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME I DATE (PRINTED 3 SIGNATURE) .,rl _. _G� llQco�-• BRYAN H. M U S C O FOR CHEVRON LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# m PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATInN - 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 PLAY THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UN ROUND STORAGE TANK REGULATIONS FORM B (6-95)