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w STATE OF CALIFORIO WATER RESOURCES CONTRA. OARD ••' FORM'13': UNDERGROUND STORAGE TANK PROGRAM #957750 TAN TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑X 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: R.J. McComb Chevron FARM TANK - YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A OWNERS TANK ID # WC5715C TB MANUFACTURED BY XERX C YEAR INSTALLED 1983 1 D TANK CAPACITY IN GALLONS: 10,000 d110nS 11. 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. ❑ i UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL F-xl 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. If C.A.S. 8006619 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 SYSTEMX❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION ❑ i STEEL/IRON ❑ 2 STAINLESS STEEL FX -j 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-15 CONCRETE F-]6 POLYVINYL CHLORIDE F77 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING F-15 GLASS LINING ❑ 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOl7 ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION O 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 U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION Ao 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 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A 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 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2 ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL' ❑ YES ❑ NO GALLONS THIS F( RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND,TO THE BES 1 OF MY KNUWLEUGE, 15 1 HUL ANU GI APPLICANT'S NAME (PRINTED 6 SIGNATURE) Pj DATE / - 9- ,- � . P 4� < 0 K) ! 'y -e / - f 1 n/lAl Af_CLld'V I lQW nLIl Y '/ RRECT. F JURISDICTION N AGENCYN FACILITY IDN TANKIDN GENCY FACILITY ID • APPROVED BY NAME PHONE 4 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE —7 -RECEIPT CHECK • PERMIT AMOUNT SURCHARGE AMT. FEE CODE • BY: FORM B (6-29-88) THIS FORM MUST NE ACCOWAIW FACLITY/911 ANILJCATOK FUHM 'A', UNLEU A C T F='A' NU BEEN FILED 1 DATA PRU,ESSING COPY 2 LOCAL AGENCY COPY J FILE COPY