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STATE OF CALII=ORN WATER RESOURCES CONTRC )ARD ••' , FORM 'B': UNDERGROUND STORAGE TANK PROGRAM #9577.5B = 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 IDN WC571 5C B MANUFACTURED BY: XERX C. YEAR INSTALLED 1983 D TANK CAPACITY IN GALLONS: 10,000 Ja11ons 11. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL F-]2 PETROLEUM 8 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 & C.A.S. N C.A.S. N.8006619 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, A D A. TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 0 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 IW%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING x 6 UNLINED ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYEMUENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E 9 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH 1€ APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A OU 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION An 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 BY: A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A pU 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 8 1 VISUAL CHECK P® 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER -- VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2 ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED 8 SIGNATURE)ATE D of�Q�b 6 TOHO�OA � -11-1.1-VI .. - nd-All Af'1•11=Yl�V IICG nul V COUNTY N m JURISDICTION M AGENCY M FACILITY ID N TANK ID N LL40NE CURRENT LOCAL AOENCY FACILITY IDA APPROVED BY NAME P 1 WITH AREA CODE LPERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 0 BY: FORM B (6-29-88) THIS FORM MUST K ACCOWANU FACL(TY/KIT APR=TWK FUmM -A-, UNLEU A CUc FM *K NU BEEN FILED .. 1 DAT,PRS.„eSSING COPY 2 LOCAL AGENCY COG'S j FMA COPY