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STATE OF CALIFORK..A WATER RESOURCES CONTRL_ BOARD ••'...... FORM `8': UNDERGROUND STORAGE TANK PROGRAM #95775D TANS( TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ® 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT 1-16 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: R.J. McComb Chevron FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A OWNERS TANK ID N WC5715C B MANUFACTURED BY: XERX C YEAR INSTALLED 1983 D TANK CAPACITY IN GALLONS: 1,000 gallons II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ® 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ® 2 WASTE ❑ 7 METHANOL ❑'99 OTHER (DESCRIBE IN ITEM D, BELOW) D IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. N C.A.S N. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B CONSTRUCTION ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1010% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE ❑ 1 RUBBER LINED F-12 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ® 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOP ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT �❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ® 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A M 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B CONSTRUCTION An 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER BY: A `U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A OU 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 I VISUAL CHECK ® S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED OUANTITY OFGALLONS 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY RY, AN T THE B ST F KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED 6 SIGNATURE) i DATE 1 Ad"Al Ar_cucv I ICF nNI v / COUNTY N m ICURRENT JURISDICTION N AGENCY N FACILITY IDN TANK ID N LOCAL AGENCY FACILITY ID • APPROVED BY NAME PHONE 1 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK t PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT • BY: FORM B (6-29-88) THIS FORM MUST K A1000WANO ' FACLRr/lM A1llxATQK FUmM -A-, UILEU A r T F 'A' NAB BEEN FILED 1 DATA PR0L;ESSING COPY 2 LOCAL AGENCY COPT v FLE COPY