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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. PGSOURCEs C P OL P 0 a C�l,Fgq NSP . MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITZ 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 - 6241 W. Paddock Place, Lodi I. TANK DESCRIPTION COMPLETE ALL ITEMS •- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# 5 - B. MANUFACTURED BY: Arrow C. DATE INSTALLED (MO/DAY/YEAR) 1983 D. TANK CAPACITY IN GALLONS: 12 � 000 ILTANKCONTENTS IFA -1 IS MARKED -COMPLETE ITEM C- A. M1 . A.1 MOTOR VEHICLE FUEL ❑ 4 OIL B. 1a REGULAR 3 DIESEL C• ❑ ❑ 6 AVIATION GAS UNLEADED F--]2 PETROLEUM ❑ 80 EMPTY jak 1 PRODUCT ❑ tbPREMIUM ❑ 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JETFUEL ❑ 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 UAQI<nN9 ITPU nNI YIN QnYF4 A R ANYIrt Akin AI I TLIAT AOOI ICQ IAI OnY n Aklll C A. TYPE OF ❑1 DOUBLE WALL F-]3 SINGLE WALL WITH EXTERIOR LINER 1--]95 UNKNOWN SYSTEM d2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL F72 STAINLESS STEEL F-]3 FIBERGLASS E]4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 6 CONCRETE A U F-11 RUBBER LINED ❑� 2 ALKYD LINING F-13 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR F]5 GLASS LINING E 6 UNLINED F-]95 UNKNOWN ❑ 99 OTHER LINING 0 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING'I ❑ ❑ 99 OTHER - 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 d91 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 11NDFRGROUNn ROTH IF APPI ICARI F A. SYSTEM TYPE A U 1 SUCTION A U P ESS A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U ST NLESS S EL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100'. METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 0 1 AUTOMATIC LINE LEAK DETECTOR 0 2 LINE TIGHTNESS TESTING'I ❑ ❑ 99 OTHER MONITORING V. TANK LEAK DETECTION �❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING IV6 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 7 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& SIGNATURE) / Michael S. Ramos 1 7-29-94 LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW 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. FOR00348-R5