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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRA .w TANK TANK PERMIT APPLICATION INFORMATIO " COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACF FA N EW ....... MARK ONLY ❑ 1 NEW PERMIT ®3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION �ppI� I7 PFERnMIA(NE 11CIO pg D ONE ITEM F-12INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURBYVI R B'TMNh`HBMOtlEO'�' y FACILITY/SITE NAME WHERE TANK IS INSTALLED: Boband Vans Chevron FARM TANK-YES NO ® z •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN WCOOOOC B. MANUFACTURED BY: Unknown C. YEAR INSTALLED 1971 D. TANK CAPACITY IN GALLONS: 10,000 Gallons W wm 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CD A. ❑X 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑X 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.G.#: 8006619 Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MEL CUD W/RBMLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 AWMINUM MATERIAL ❑B 100%METHANOL COMPATIBLE FAP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑R 6 UNLINED ❑ 95 UNKNOWN ❑ IS UNING MATERIALCOMPATIBLEWTTH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PUSTIC PROTECTION 0 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 1 SUCTION A Q0 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION AR 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 A U 1 STEEL/IRON AO 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. i P S 1 VISUAL CHECK P O 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER i 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 ALLONS INERT MATERIAL? ❑YES E]NO THIS FORM HAS BEEN COMPLETED UNDER PE L PERJU ND TO TbE B F MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE ` �qy LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N CILITY ID N TANK ID# v I t I/ 15 101010Z CURRENT LOCAL AGENCY DFACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE Gfr��Y� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 1 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# FORMB(6-29-66) THIS FORM MUST BE ACCOMPANIE3BY A FACILITY/SITE APPLICATION, FORM 'A',UMLESSA RRENT FORMA' HASBEENFILED DATA PROCESSING COPY