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soy"yes STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B n3; . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D. # 1 B. MANUFACTURED BY: Arrow C. DATE INSTALLED (MO/DAY/YEAR) 1983 D. TANK CAPACITY IN GALLONS: 12,000 ® 1 PRODUCT 4 GASAHOL ❑ 1b PREMIUM ❑ ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ® 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Saddle City Chevron -6421 W. Paddock Place, Lodi I. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK 1. D. # 1 B. MANUFACTURED BY: Arrow C. DATE INSTALLED (MO/DAY/YEAR) 1983 D. TANK CAPACITY IN GALLONS: 12,000 II -TANK CONTENTS IFA-11.CMARKFf1Cf1MPIPTPITCMC A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ® to REGULAR 3 DIESEL ❑ 6 AVIATION GAS DED ❑ 2 PETROLEUM ❑ 80 EMPTYE ® 1 PRODUCT 4 GASAHOL ❑ 1b PREMIUM ❑ ❑ 7 METHANOL UNLEADED ❑ 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 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 ROXFR A R ANO C AM) AI I THAT APPI IGC IN Rr)Y n ANf1 C A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM EZ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL F-]2 STAINLESS STEEL F-]3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Pr)maryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL a 95 UNKNOWN ❑ 99 OTHER F-]1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING V6 UNLINED F-]95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO— D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE V95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNDFRGROUND. BOTH IF APPI IGARI F A. SYSTEM TYPE A U 1 SUCTION A U 2 !DE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 11 GL L A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND CORROSION PROTECTION A U A U A U 1 ST 5 ALUMINUM 9 GALVANIZED STEEL A U A U A U 2 STAINLESS STEEL A U 6 CONCRETE A U 10 CATHODIC PROTECTION 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL W/ COATING A U A U 95 UNKNOWN A U 4 FIBERGLASS PIPE 6 100% METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3N MONERSTITIAL ITORING ❑ 99 OTHER V. TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ET 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE O 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MO/DAY/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 YES E] NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME �+ DATE (PRINTED B SIGNATURE) Michael S. Ramos 1 7-29-94 LOCAL AGENCY USE ONLY THE STATE I.D NUMBER IS CO%IPOSFD OF THE FOUR NUMBERS BELOW FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0030-R5 COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# ❑ PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FOR0030-R5