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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM #9549)10n TANK TANK PERMIT APPLICATION INFORMATI COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION F MARK ONLY ❑ I NEWPERMIT ❑X 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 10M 7 PEPBIAM�IIMI CLOSE 7 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CZR. A v �LMD7D7VUU b FACILITY/SITE NAME WHERE TANK IS INSTALLED: Bob and Vans Chevron T NO X O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID WC0000C B. MANUFACTURED BY: Unknown W C.YEAR INSTALLED 1971 D. TANK CAPACITY IN GALLONS: 1,000 Gallons W Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Q A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT X❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN O 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CA.S.# C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,s D A.TYPE OF ❑ 1 DOUBLEWAUED ❑3 BNGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ®2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ®2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WNIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 10096 METRANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER i F-] 1 RUBBER UNED ❑2 ALKYD LINING F-13 EPDXY UNING ❑4 PHENOLIC UNING C.INTERIOR 5 GLASS UNING X LINING ❑ 6 UNLINED 95 UNKNOWN ❑ ❑ ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAA OR ASPHALT ❑3 VINYLWRAP ❑4 RBERGLASSREINFORCEDmASITC li PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑W OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A M 1 SINGLE WALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELMRON AO 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8109%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. P S 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 8 7 PRESSURETESTING 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 OALLONB SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER P OF PER46R , D O TkhEST OF AMI'KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE DAV 17 SO FJ" LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# V FACILITY ID# TANK ID# EEI =1 10101 / I= 161010E CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY MAKE PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERYff AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# 2 FORMB(6-29-88) THIS FORM MUST BE ACCOMPANI BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS-A RRENT FORMA' HAS BEEN FILED V J1 DATA PROCESSING COPY - _