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�,oURCe STATE OF CALIFORNIA 4.P �Ot STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B o= 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 ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Y2 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Saddle City Chevron - 6241 W. Paddock Plcae, Lodi 1. TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 3 B. MANUFACTURED BY: Arrow C. DATE INSTALLED (MO/DAYNEAR)l 9 8 3 D. TANK CAPACITY IN GALLONS: 12,000 II_ TANK CONTENTS IP A.1 I.4MARKP:nrnMPIPTP ITPMC A. [a 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. ❑ laREGULAR C.❑ 3 DIESEL ❑ 6 AVIATION GAS UNLEADF-1b 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT iPREMIUM ❑ 4 GASAHOL ❑ 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 ITFM nNI Y IN ROXPS A R ANIS C ANI) Al I TWAT APPI IFR IN Rl1X rl ANII C A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 5�11 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK Z'1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009/6 METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING E]3 ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING EP -16 UNLINED ❑ 95 UNKNOWN n 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 �5 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. ROTHIFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 RES 9E A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 I F 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 BARE STEEL 5 ALUMINUM 9 GALVANIZED STEEL A UAI A U A U LESSS 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 8 1009/6 METHANOL COMPATIBLE W/FRP 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING E]3 MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 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? YES ❑ 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 A SIGNATURE) //f�/J Michael S. Ramos 7-29-94 LOCAL AGENCY USE ONLY THE ST ATF I.D. NUMEER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # STATE I.D.# ❑ I I 111F] 11111111 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. FOR0034 B -RS