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�Sau�cts STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B m� 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 ITEM F-12 INTERIM PERMIT E-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Ul 8 TANK REMOVED / Q DBA OR FACILITY NAME WHERE TANK IS INSTALLED: CHEVRON SERVICE STATION 301 W. KETTLEMAN LANE, LODI I. TANK DESCRIPTION COMPLETE ALL ITEMS — SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D. # 2170 B. MANUFACTURED BY: X E R X E S C. DATE INSTALLED (MO/DAYNEAR) 1 9 8 3 D. TANK CAPACITY IN GALLONS: 10,000 II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. A ® 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL O 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY Fx1 1 PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ® 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN El2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM FXI 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL )bD 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO 1 MECHANICAL LINE LEAK ❑ D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ED 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL, etc. SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) UNKNUWN DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 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)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STLLL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION U5 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 MECHANICAL LINE LEAK ❑ 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC UNE ❑ 5 AUTOMATIC PUMPFX 99 OTHER I nl K N n III N DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION MONITORING ❑ 3 VADOZE MONIITORING 1:1 TANK 4 AUTOMATGAUGING IC TANK ❑ 5 GROUND MONITORING TER ❑ 6 ANNUALTESTING ❑ 7 CONTINUMONITOR U INTERSTITIAL ❑ 8 SIR ❑ 9 WEEK LY MANUAL [:]10 MOTESTINGHLY TANK 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1.T MA YES NO D DATE T6T U ED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH ❑ I 31 , 1 �J 9 SUBSTANCE REMAINING STILL I N GAt6Jws INERT MATERIAL ? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAMF. I DATE (PRINTED& SIGNATUR BRYAN H. MUSCO FOR CHEVRON 7/13/98 iv LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # 1 I FACILITY # / TANK # STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY/DATE MIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT 4. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TNr I INDERGROUND STORAGE TANK REGULATIONS FORM B (6-95)