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S J STATE OF GALIFORNO WATER RESOURCES CONTRG, OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM 495775C TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: R.J. McComb Chevron FARM TANK - YES ❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID q WC571 5C B MANUFACTURED BY: XERX C YEAR INSTALLED 1983 D TANK CAPACITY IN GALLONS: 10,000 gal Ions II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 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 8 C.A.S. 4 C.A.S. W 8006619 _j III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A. B, C, a D A. TYPE OF ❑ i DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 0 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL [3j 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-15 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-]7 ALUMINUM F—]8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER U I STEEL/IRON ❑ 1 RUBBER LINED F-12 ALKYD LINING ❑ 3 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR LINING F-]5 GLASS LINING FX -j UNLINED A F-195 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED 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 I SUCTION A UO 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B CONSTRUCTION A O 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER RECEIPT 0 BY: A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A© 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 8 100% 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 CIRCLED. P S 1 VISUAL CHECK P OS 2 INVENTORY RECONCILIATION P 5 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER —_ VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF G 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO ALLONS Tulc cnp&4 RAS BEEN C.OMPI FTFD IINDFR PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, APPLICANT'S NAME (PRINTED & SIGNATURE) } . DATE wvr�r n COUNTY # JURISDICTION K m ICURRENT AGENCY M FACILITY ID N TANK ID N LOCAL AGENCY FACILITY ID • APPROVED BY NAME PHONE d WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 0 BY: FORM B (6-29-88) THIS FORM MUST K ACCOWAME' ' A FACSJTYtVIl APF=TWK r V"M -A-, URLM A i- I PUSS'A- MM B[eN raeU 1 DATA PRUCESSING COPY 2 LOCAL AGENCY COPY 4, FILE COPY