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STATE OF CALIFORA WATER RE 0E vARD FORM 'B': UNDERGROUND STO ti � KK,,�PRI�Z; AM #96465A r TANK TANK PERMIT APPLICATI N'II FO"'iTION COMPLETE A SEPARATE FORM WITH T}fE[ 1 S'! C L (!REACH TANK. MARK ONLY ❑1 NEW PERMIT 3 RENEWAL PERMIT PEM'154 � EQC 1�t6&60N ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 01 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Pershing Chevron FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-s0 SPECIFY A. OWNERS TANK ID N WC7706CB. MANUFACTURED BY: ovum C. YEAR INSTALLED 1988 1 D. TANK CAPACITY IN GALLONS: 10,000 aHonS II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑X 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM 8' C. ❑1 UNLEADED ®2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ®1 PRODUCT ❑0 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY E-]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.N C.A.S.N: 8006619 III. TANK CONSTRUCTION NARK ONE ITEM ONLY IN BOX A B,C,A D A TYPE OF ❑X I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTEROR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ t STEEL/IRON ❑2 STAINLESS STEEL ®3 FIBERGLASS ❑4 STEEL W/RBFAGLASS REINFORCED FUSTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 IMMETHANOLCOMPATIBURIP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBERLINED ❑2 ALKYD LINING ❑3 EPDXYLINING ❑4 PHENOLIC UNING LINING X❑5 GLASS LINING ❑6 UUNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITN 10016 METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYE7NLENEWRAP ❑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 1 SUCTION A 6D 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A@ 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A Q 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 8109M 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© 2 INVENTORY RECONCILIATION ■ S 3 VADOSE WELLS O B 4 ELECTRONIC MONITOR P / 5 GROUND WATER MONITORING WELLS P / 6 PRECISION TES TING P 6 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 IMO/YR) 2.ESTIMATED OUANTITY OFDALLOMS 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY JURY,A TOT E E OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6510 NATURE) DATE i . To i4t0SD AI - -?0 —Po LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N ACILITY ID N TANK ID N 9 = 7 7 CURRENT LOCAL AGENCY FACILfTY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMTT EXPIRATION DATE CHECK 4 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT A BY: FORM816-29-eel THIS FORM MUST BE A FACBm/mE APPLICATION, FORM 'A', FORMA' HASBEENRLED 1 DATA MESSING COPY 2 LOCAL AGENCY FILE COPY