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STATE OF CALIFORNIA t STATE WATER RESOURCES CONTROL BOARD i , UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM B y COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT i 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY Cj400@jbflLkX ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOV DBA OR FACILITY NAME WHERE TANK IS INSTALLED:Chevron Station # -7-01"1 1. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.4 ` , B. MANUFACTURED BY: C r !(f?S C. DATE INSTALLED(MO(DAYIYEAR) � ' Zj(�-Cr Z D. TANK CAPACITY IN GALLONS: t 2 60o II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. A h MOTOR VEHICLE FUEL 4 OIL B. C. ❑ 1a REGUG LAR 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ Ib PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ UNLEADED 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE LEADED 9JET L 2 9OTHER (DESCRIBE IN ITEM D. BELOW) .�" D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED M 1 r-,-, _ C.A.S.III: 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 ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEELti,-3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 6� MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES 1 POLNO— D.CORROSIONYETHYLENE WRAP. Q ; ❑ ❑2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION M-!S.CATHOPIGPROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION ` OracLE A IFABOVEG ` NDOR U iFUN'DtRGROUND,BQTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A; PRESSURE, .. A-U- 1(;RNVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A 4j,,A 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 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 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 E `1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ J MONRSTITIAL TE ITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING Y4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING 1�r 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 YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT ' APPLICANTS NAME (PRINTED&SIGNATURE h.0. •f11r.7"1L - (d' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF HE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# ❑ '� PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITLOCAL AGENCY IMPLEMENTING THE UNDERGROUND fVGE TANK REGULATIONS FORM B (12-91) FORDW411-RS