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STATE OF CAUFORIAA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM B ae COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT W/ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE ❑ A TANK REMOVED DBAOR FACILITY NAME WHERETANK IS INSTALLED:Chevron Station # p 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.a B. MANUFACTURED BY: LAD S C. DATE INSTALLED(MO/DAYIYEAR) q 1229 RD D. TANK CAPAC17Y IN GALLONS: L'L 000 ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. ICJ E] ❑ 1*REGULAR 3 DIESEL ❑ 6 AVIATION GAS A 1 MOTOR VEHICLE FUEL ! OIL B. C. ❑ 2 PETROLEUM ❑ SD EMPTY ® 1 PRODUCT ❑ IbPREMIUM 4 GASOHOL ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 3 CHEMICAL PRODUCT ❑ BS UNKNOWN E] 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D.BELOW) D. IF(A.11 IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND TR A. TYPE OF L.�I / DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER S. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL �Z 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑�yy 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR IBJ 5 GLASS LINING F--] 8 UNLINED LINING 1:395 UNKNOWN ❑ 99 OTHER ISS L LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 15e 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A a 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AU 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)A4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL' A B IOD% METHANOL COMPATIBLE W/FAP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ i AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING MONRORING ❑99 OTHER V.TANK LEAK DETECTION CI 1 VISUAL CHECK '� 2 INVENTORY RECONCILIATION F73 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING [:] 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN E] 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENAL TYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRll R 61G.AT. El LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPO ED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION 9 FACILITY L_I—1—LIJ TANKN� STATE I.D.# d 8 2 11 v PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE 6 K THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM 8 (1291) FILE THIS FORM WITH IWAL AGENCY IMPLEMENTING THE UNDERGROUND STIVE TANK REGULATIONS fd19WILW