COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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STATE OF CALIFORP% WATER RESOURCES CONT0 ARD ' FORM `BUNDIRGROUND STORAGE TANK PR #94183C TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY F-1 1 NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM F-1 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Lakewood Chevron FARM TANK-YES D NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# WC5728C B. MANUFACTURED BY: Unknown C.YEAR INSTALLED 1969 D. TANK CAPACITY IN GALLONS: 5,000 Gallons 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 F-] 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT 0 4 OIL Fx-1 1PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS 0 80 EMPTY D 95 UNKNOWN 2 WASTE El 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S. AQQ66L9- GENFif III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D " E A.TYPE OF F-] 1 DOUBLE WALLED F--]3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER JUN 8 1990 T F� 1 STEEL/IRON EK] 2 STAINLESS STEEL F-]3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLY A44M599�� A L H B.TANK F7 5 CONCRETE F-16 POLYVINYLCHLORIDE F--] 7 ALUMINUM E]8100%METHANOL COMPATIBLE FRPERM IT/SERVI CES I MATERIAL [::] 9 BRONZE 10 GALVANIZED STEEL [::]95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-]3 EPDXY LINING ❑4 PHENOLIC LINING 5 GLASS LINING FX-1 6 UNLINED 95 UNKNOWN LINING F-] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E:j YES E] NO 0 99 OTHER D.CORROSION F-1 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT F-] 3 VINYL WRAP F-1 4 FIBERGLASS REINFORCED PLASTIC PROTECTION Ej 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER I- IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A @ 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A0 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 • U 1 STEEL/IRON AO 2 STAINLESS STEEL 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 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP • 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 : 1 VISUAL CHECK P @ 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH I SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENH PERJUR ,A TO T BENrjO MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# WLITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE LL PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT . SURCHARGE AMT. FEE CODE rRECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ARENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY