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Vw�tS STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B m� 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 ® 6 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CHEVRON SERVICE STATION 301 W. KETTLEMAN LANE, LODI I. TANK DESCRIPTION COMPLETE ALL ITEMS – SPECIFY IF UNKNOWN A. OWNER'S TANK I. D. N 2171 B. MANUFACTURED BY: X E R X E S C. DATE INSTALLED (MO/DAYNEAR) 1983 D. TANK CAPACITY IN GALLONS: 10,000 II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. q. ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN B. ® 1 PRODUCT ❑ 2 WASTE C 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ ib PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0. BELOM 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 a] 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 1GO% 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 ❑X ( 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— 5 UNKNOWN D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE E995 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 Qc1 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 AZI95 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 U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 MECHANICAL UNE LEAK ❑ 2 LINE TIGHTNESS 3 CONTINUOUS ❑ INTERSTITIAL E:]4 ELECTRONIC UNE ❑ ❑ 5 AUTOMATIC PUMP �yy ^ T 99 OTHER I I N K N DI N DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN I V. TANK LEAK DETECTION ❑GROUND WANUAL 1 VISUAL CHECK ❑ 2MANUAL RECONCILII TIONVENTORY ❑ 3 MONITORING ❑ VADOZE4 GAUG NGAUTOMATIC TANK ❑ 5 MON TORINGTER ❑ 6 TESTINGTANK ❑ 7 MONITORING INTERSTITIAL [_]8 SIR ❑ 9 WEEK LY M GAUGING ❑ 10 MONTESTHLY TANK 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ED NO ❑ T 1 11 V 31 , l q q R SUBSTANCE REMAINING 51�1. q(� LONS 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 a SIGNATUR BRYAN H. MUSCO FOR CHEVRON 7/13/98 LOCAL AGENCY USE 0 LY 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 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 PU '.E THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE V 'GROUND STORAGE TANK REGULATIONS FORM B (6-95)