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STATE OF CALIFORN..A WATER RESOURCESCONTROw4OARD FORM V: UNDERGROUND STORAGE TANK PROGRAM #90557D _� TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT AL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ANK REMOVED FACILITY/BITE NAME WHERE TANK 18 INSTALLED: ROILS Personalized Chevron Service FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID K WC5718C B. MANUFACTURED BY: unknown=. C.YEAR INSTALLED 1969 0. TANK CAPACITY IN GALLONS: ; ,.'F"OX10,g $11O II. TANK CONTENTS IF IRA),IS MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADEDf �FT--1 3 ESEL^ ❑3 CHEMICAL PRODUCT ©4 OIL ❑ 1 PRODUCT ❑4 GASAMOL ❑3 �}.j I��:Nil..l d AI(1FI;QA& ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ©2 WASTE ❑7 METHANOL ❑99 OTI(L { $E 1NJA}�'LB�{ 'Y1,� D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CAS.A CA.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,0,C,&D A TYPE OF ❑ 1 DOUBLE WAILED ❑3 SINGLE WALLED WITH EXTEROR LINER ❑%UNKNOWN SYSTEM ❑X 2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELARON ©2 STAINLESS STEEL ❑3 RBERAA% ❑4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC 8.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 1O METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C.INTERIOR LINING ❑ 5 GLASS LINING ©6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER r SION ❑ I POLYET&ENE WRAP ❑2 TARORASPHALT 3 WWIL WRAP 4 FIBERGLASS REINFORCED RUSTICCTION ©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 I SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U M UNKNOWN A U BOTHER B.CONSTRUCTION A @ I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U %OTHER A U I STEEL/IRON A O 2 STAINLEMSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUDW/FRP A U B 1(10%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 { t VISUAL CHECK { 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P { 6 PRECISION TESTING P { 7 PRESSURE TESTING P { 91 NONE P { 95 UNKNOWN P 8 99 OTHER_ VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PUKE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GAAk"8 INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P FUU , DT T OF K OWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE Q ( l SOI 7 LT /O LOCAL AGENCY USE ONLY COUNTY R JURISDICTION K AGENCY{ FACILITY ID R TANK ID E CURRENT L AL AGENCY FACILITY 10 P APPROVED BY MAINE PHONE•WITH AN"CODE V / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT UNRATION DATE CHECKS PERMIT AMOUNT WRCHAAOE ANY. ME CODE RECEIPTS BY: FORMB(6-29-83) THIS FORM MIMTMACCOWAMF^BTAFACBJTYWRIAPMCMTKNA FORM'A',UMEMACIIBMR FOA W IMSIEENFRED 1 DATA P.00ESSING COPY 2 LOCAL AGENCY CAPD --d FILE COPY