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STATEOFCALIFORMA „ s STATE WATER RESOURCES CONTROL BOARD e' UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM B e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE REM F—] 2 INTERIM PERMIT ❑ a AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ A TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED:Chevron Station # A007�a I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a B. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: O ILTANKCONTENTS IFA I IS MARKED,COMPLETE ITEM C. FVI 1 MOTOR VEHICLE FUEL ❑ a OIL B. C. ,❑ 1aUN UNLEADED 8 REGULAR 3 GAS/i1L10L ❑ 8 AVIATION GAS A 2 PETROLEUM ❑ BO EMPTY 1 PRODUCT Ill 1E PREMIUM ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE Y❑" 2 LEADED 99,ET OTHER (DESCRIBEIN ITEM D. BELOW) 0. IF(A.1)IS NOTMARKED, 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 A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 25 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK)' ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 10D% METHANOL COMPATIBLE WA-RP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR LINING pi 5 GLASS LINING F—] 6 UNLINED ❑ 95 UNKNOWN C:] 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A W2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A ti-2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A VS 10D% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION DC 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 WERST IALMONING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING E:] K AUTOMATIC TANK GAUGING ❑ 6 GROUND WATER MONITORING ❑ 6 TANK TESTING12 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ N 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 I INERT MATERIAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED A SIGNATURE) r r LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOS D OFT-HE FOUR NUMBERS BELOW COUNTY# JURISDICTION* FACILITY# TANK#OOA STATE I.D.# m Fm $ 1,2 11 0 kj PERMIT NUMBER PERMITAPPROVED BYIDATE PERMITEXPIRATKON DATE 3 � THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH IWAL AGENCY IMPLEMENTING THE UNDERGROUND ST(WE TANK REGULATIONS FORM B (1291) F0115m16%