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STATE OF CALIFORNI0 WATER RESOURCES CONTROLIOARD <br /> J <br /> FORM 'S': UNDERGROUND STORAGE TANK PR <br /> TANK TANK PERMIT APPLICATION NFOR ' <br /> ^.._/ COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMA <br /> (� MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATWPAY 7 NENTLY CLOSED TA <br /> ONE ITEM 2 INTERIM PERMIT M4 AMENDED PERMIT E]6 TEMPORARY VTfMI V M-I��A" ;C o <br /> FACILITY/SITE NAME WHERE TANK 18 INSTALLED. AndyS Chevron FE R�I 0 * 7 <br /> S NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# WC6187C B. MANUFACTURED BY: XERX <br /> C. YEAR INSTALLED 1984 D. TANK CAPACITY IN GALLONS: 10,000 gallons <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ® 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ® 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL ©1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.W 8006619 <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.i D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM QX 2 SINGLE WALLED E]4 SECONDARY CONTAINMENT 99 OTHER <br /> I STEEL/IRON 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F-1 5 CONCRETE 6 POLYVINYL CHLORIDE [:]7 ALUMINUM E:]8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL E]95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED E—]2 ALKYD LINING �3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR <br /> IN NG R F-1 5 GLASS LINING QX 6 UNUNED Ej 95 UNKNOWN <br /> 0 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO 99 OTHER <br /> D.CORROSION ❑1 POLYETHLENE WRAP 2 TAR OR ASPHALT F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:]5 CATHODIC PROTECTION QX 91 NONE E:j 95 UNKNOWN Ej 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U 1 SUCTION A E5 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 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 <br /> A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A 04 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 8 1 VISUAL CHECK P SO 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> 6 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER_ <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN ON$ INERT MATERIAL? [:]YES [—]NO <br /> TH/S FORM HAS BEEN COMPLETED UNDER PENALTY O Y,AN T HE EST Wy KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> `-C kirD G--- abt4NSoraV-'�v � 1 4-d6 � <br /> LOCAL AGENCY USE ONLY 1 17 <br /> EPERMITNUMBM <br /> JURISDICTION# AGENCY# F ITY ID# TANK ID# <br /> ld 1® 7 1& FOTO�ol <br /> NCT FACILITY IDM APPROVED BY NAME PHONE•WITH AREA CODE <br /> PERMIT APPROVAL DATE RMIT EXPIRATION DATE <br /> PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: <br /> FORM B(62(j-88) THIS FORM MUST Bt:ACCO A FACi1TT/IRE AFF�IC =K FORM'A',UNLESS A F='A' IMI BEEN FILED <br /> frN.E COPY <br /> o � <br /> ° � 1 DATA PN�CESSING COPY 2 LOCAL AGENCY COPT <br />