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• STATE OF CALIFORNIA '`° °' ° STATE WATER RESOURCES CONTROL BOARD � g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B =° ° COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY EN, 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B T K 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Lodi Dodge Chrysler Plymouth n (� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN V I1 �0 LI IJ A OWNER'S TANK I.D.# Tank In parts room floor B. MANUFACTURED BY: Unkn OW C. DATE INSTALLED(MO/DAYNEAR) Unknown D. TANK CAPACITY IN GALLONS: E O olmw II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. -- A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT E:] 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL It MIDGRADE UNLEADED 5 JET FUEL ❑ B M85 ❑ 3 CHEMICAL PRODUCT ❑ BS UNKNOWN ❑ 2 WASTE ❑R 2 LEADED ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.a 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 L-.AJ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK u 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PfI111Bfy TMk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ® 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ® 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,BTC. SPILL CONTAINMENT INSTALLED(YEAR) nn OVERFILL PREVENTICZp EQUIPMENT INSTALLED(YEAR) no DROP TUBE YES NO A STRIKER PLATE YES NO A DISPENSER CONTAINMENT YES_ NO X IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A V 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A ID 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 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 10D% METHANOL COMPATIBLE W/FRP PROTECTION A ID 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 MECWMCAL LME LEAN 2 LME TIa1R W 3 CCWINU MTEASTRMI 4 ELEt7AMIC UNE 5 AUTOIMPC PUI.V �TECTM ❑ TESTING ❑ uOMTcaINO E] Um CETECmA ❑ Avu"=C 99 OTHER none V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING E] 3 MAONNIITORING ZE E] 4 GAUGING MONITORING TANK E:] 5 GROUND MONTORING�R F-18 ANNUALTESTINGTANK ❑ 7 MONITORU INTERSTITIAL ❑ 8 SIR ❑ 9 TANK LY MANUAL E] 10 MOTESTINGHLY TANK ® 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST USED(MO/DAYNR) 2.ESTIMATED QUANTITY Of 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS 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 NAMEW lChard Inorpe, Contractor DATE 1 (PRIMED A$IGNATURE) 2117/00 LOCAL AGENCY USE ONLY THE STATE I.D.NUM RIS COMPOSE FTHE 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)