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STATE OF CALIFORA WATER RESOURCES CONTRIOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM " 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 ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED-.CHEVRON USA INC. 4747 W.LN. DAVIS FARMTANK-YES❑ NO7❑X I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN UNKNOWN B. MANUFACTURED BY: N7 NT CORNTNG C. YEAR INSTALLED (990 D. TANK CAPACITY IN GALLONS: 12,000 IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ® I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL ® 1 PRODUCT A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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 6 C.A.S.N C.A.S. Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C,1110 A TYPE OF I DOUBLE WALLED ❑3 SINGLE WALLED WITH E%TERKM LINER ❑%UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL )E]3 FIBERGLASS ❑A STEEL CUD WIFIB B.TANK ❑5 CONCRETE ❑6 PO.YVINYLCHLCRDE E] 1 ALUMINUM E]B 100%METI4ANOL EKE' MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑%UNKNOWN ❑99 OTHER ❑ I RUBBERUNED ❑2AUOD LINING ❑3EPDXY LINING ❑4 PHENOLK;DNIEN VIRONMENT AL HEALTH C. INTERIOR IN NG R ®5 GLASS LINING F-16 UIKINED [:]95 LINK. ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑%OTHER PERM I T/SE W C H) D.CORROSION ❑ 1 POLYMCENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑1 FIBERGLACSREINFORCEDPLASTIC PROTECTION ❑5 CATHODIC PROTECTION EZ 91 NONE ❑ 95 UNKNOWN ❑ %OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U %UNKNOWN A U 99 OTHER A U I STEELPRON A U 25TAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4FIBERGUSS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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. I VISUAL CHECK P f 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS F /ELEOTRONIC MONITOR P t s GROUNDWATER MONITORING WELLS Y 6 PRECISION TESTING P t 7 PRESSURE TESTING F t 91 NONE t 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE UST USED(MO/YR) 2 ESTIMATEDOUANTITYOF 3.WAS TANK FILLED WITH NIA SUBSTANCE REMAINING IN N/A GALLON{ INERT MATERIALT N/ DYES ❑ 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&SIGNATOR DATE HELEN LORETn G�- ! o s LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID a TANK ID N K CURRENT LOC AL AID NC FACILITY APPEO DlYNA7 _ ! ._/,n PHONE N WITH AREA COD! ah PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE co" RECEIR N my: FORM a(e.29-ee) THIS FORM MUBT BE AccGwMw SY A FAumME APRICC•TKIN, FORM'A',UOLESS A euRMKT fD -M NAA SEEN FILED ,� '�I_ 1 DATAWCESSING COPY 2 LOCAL AGENCY COP& FSE COPY