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4 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> APR 9 1991 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> ENVIRONMENTAL HEALTH <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. #764 <br /> MARK ONLY ❑ 1 NEW PERMIT ® 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED O' <br /> DBAOR FACILITY NAME WHERE TANK IS INSTALLED: Chevron U.S.A. Inc: ''7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# _______ B. MANUFACTURED BY: DT <br /> C. DATE INSTALLED(MO/DAY,YEAR) 9/28/90 D. TANK CAPACITY IN GALLONS: 1 2,000 <br /> ILTANKCONTENTS IFA-I IS MARKED,COMPLETE ITEMC. <br /> A ® i MOTOR VEHICLE FUEL ❑ 4 OIL 8. C. ❑ laREGULAR <br /> EO 3 DIESEL ❑ 6 AVIATIONGAS <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY ® 1 PRODUCT ❑ -b- 4 GASAHOL ❑ 7 METHANOL <br /> UNLEADED ❑ 5 JETFUEL <br /> ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ® 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.a: 8006619 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF ® i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ® 3 FI8ERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ® 5 GLASS LINING ❑ 6 UNLINED ❑ <br /> LINING 95 UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— <br /> D.CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ® 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A X 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A K 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A IX 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ® I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3INTERSTITIAL MONITORING ❑99 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECKX❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL YES ❑ NO❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF Y,AN O HE ST MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAMEDATE <br /> (PRINTED B SIGNATURE) <br /> DILL 6r.LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE F4 NUM R ELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE I.D.# m <br /> PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE <br /> FORM B (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOR00314VBR4 <br />