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STATE OF CALIFORNI,.. WATER RESOURCES CONTROL . )ARD FORM V: UNDERGROUND STORAGE TANK PROGRAM #90557C TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK QO MARK ONLY ❑ 1 NEW PERMIT -GO RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 NENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WMERE TANK IS INSTALLED., Ron's Personalized Chevron Service FRAY TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN WC5718C B. MANUFACTURED BY: Unknown C. YEAR INSTALLED 1969 D. TANK CAPACITY IN GALLONS: 10,000 gallons II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. ® 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ©1 UNLEADED ❑2 LEADED ❑3 DIESEL F-] 3 CHEMICAL PRODUCT ❑A OIL © 1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF T` HAZARDOUS SUBSTANCE STORED 6 CAS,p sCh& '8(1(1661'9 Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,S,C,S D m,nY 39 A TYPE OF ❑ I DOUBLE WALUD ❑3 SINGLE WALLED WITH E%1ERION UNER ❑95 UNKNOWN _._ V i{( j'•Y (. SYSTEM ❑X 2 SINGLE WAU.ED ❑1 SECONDARY CONTAINMENT ❑%OTHER _ - I ❑ 1 STEEL/IRON ©2 STAINLESS STEEL ❑3 RBEAGLASS ❑X STEEL CLAD WIFIBERGUSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6 100%WUMNOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-1I RUBBER LINED E]2 ALKYD LINING ❑3 EPDXY UNING ❑A PHENOLIC LINING CRITERION! LINING F-]5 GLASS LINING ®6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 18011 METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETILENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ® 5 CATHODIC PROTECTION ❑91 NONE ❑%UNKNOWN ❑%OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A 0 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 1.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A U 95 UNKNOWN A U S9 OTHER A U I STEEL/IRON A OU 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U A 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 B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U W OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. t III CHECK P 2 INVENTORY RECONCILIATION P R 3 VAOOSE WELLS ► t A ELECTRONIC MONITOR P t s GROUND WATER MONITORING WELLS P 6 6 PRECISION TESTING P 6 T PRESSURE TESTING P t 91 NONE P It 95 UNKNOWN P t "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH OALLOIY SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF RY,Aygj�THE BrS-T'VW KNOWLEDGE,IS TRUE AND CORRECT. 1APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE 0vl Ih SVA LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY* FA 'ITY ID N TANK ID t T CURRENT LOCAL AGENCY FACIA. 13• APPROVED BY NAME b MNEA E P WYFN ARCODE 4 - l PERMIT NUMBER PERMIT APPROVAL DATE PERMIT QPIMTOM DAT[ CHECK F PERMIT AMOUNT N/RCHAROE AMT. FEE CODE RE"I"N BY: FORMB(6-29-BB) THIS FORM MUST MACDOWAwPnAFACLRYmumnm'nOK FORM'A',M MACPPRIKT NINSIN NASBEENFKED 1 DATA PN.,CESSING COPY 2 LOCAL AGENCY COPE —o FILE COPY