COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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STATE OP CALIF0 WATER RESOURCES CONT OARD F ` ': I I UNDIRGROUNDSTORAGE #94183Aa TANKTANK PERMIT APPLICATION INFORMATION O t LEtE A lEkkkkm FORM WITH THE FOLLOWING INFORMATION FOR tACijTANK: MARK ONLY ❑1 NEW PERMIT ®3 RENEWAL PERMIT F--j 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: Lakewood Chevron FARM TANK-YES❑ NO I. TANKDESCRIPTION` COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY EA.OWNERS TANK ID# WC5728C B. MANUFACTURED BY: Unknown C. YEAR INSTALLED 1969 D. TANK CAPACITY IN GALLONS: 1,000 Gallons 11. TANK CONTENTS IF(A.1),Is MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,COMPLETE ITEM D. A.,❑ 1 MOTOR VEHICLE FUEL ® 2 PETROLEUM B. C. El ' UNLEADED 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ®4 OIL F-11 PRODUCT ❑4 GASAHOL 5 JETfUEL ❑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 Ask, EKE m u 'Em, HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A. #: U I v III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&DJUN 8 1990 A TYPE OF 1 1 DOUBLE WALLED ®3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN N V L L y r u SYSTEM 2 SINGLE WALLED Ej 4 SECONDARY CONTAINMENT ❑99 OTHER !T L n Rv 1 STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE 6 POLYVINYL CHLORIDE F-]7 ALUMINUM Ej 8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL [::]95 UNKNOWN ❑99 OTHER 1 RUBBER LINED ❑2 ALKYD LINING F-�3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑ LINING 5 GLASStiNING ®6 UNLINED ❑95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES 0 NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ®5 CATHODIC PROTECTION Ej 91 NONE E:]95 UNKNOWN E-] 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND,U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A g 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A a1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A0 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 STEEL CLAD W/FRP A U 6 100%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 S 1 VISUAL CHECK Q S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S' 6 PRECISION TESTING P S 7 PRESSURE TESTING 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? F-1YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PE OF PERJ Y,AND fO)VEBfST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE t LOCAL AGENCY USE ONLY 7-11 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# LLJ L L I I I 1-T I I 111 EI I I I CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM s(6-29-88) THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATION, FOR `A'UNLESS A. ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY