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STATE OF CALIFORINO WATEWRESOURCES CONTROWARD <br /> FORMV: UNDERGROUND STORAGE TANK PROGRAM #99840A <br /> T I APPLICATION INFORM <br /> ` '` <br /> COMPLETE PAS TEfORM O tN[It� Tlld <br /> TANK <br /> . ., <br /> MARK ONLY ❑1 NEW PERMIT 013 RENEWAL PERMIT 5 CHANGE OF INFORMATION AY jPEj TLY CLOSED T <br /> ONE ITEM ❑2'INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANKss T NK REMOVED ri ' <br /> FACILITY E WHERE TANK IB INSTALLED. Arid s Chevron K NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN SPECIFY <br /> A. OWNERS TANK ID# WC6187C B. MANUFACTURED BY: XERX <br /> C.YEAR INSTALLED 1984 0. TANK CaPAC�TY IN GALLONS 10 000 dons <br /> IL TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1},IS NOT MARKED,COMPLETE ITEM D. <br /> A. ® i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED 2 LEADED ®3 DIESEL <br /> Q 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ®4 GASAHOL ®5 JET FUEL ❑6 AVIATION GAS <br /> Ej 5 HAZARDOUS ®60 EMPTY ❑95 UNKNOWN 2 WASTE ®7 METHANOL ®99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.q: <br /> Ill. TANK CONSTRUCTION MARK ONE rrEm ONLY IN BOX A.B.C,A D <br /> A OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH Woom LINER ®95 UNKNOWN <br /> SYSTEM a 2 SIDLE WALLED ®4 SECONDARY CONTAINMENT ❑99 OTHER <br /> ®i STEELARON ®2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CURD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK MATERIAL ®5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 6 100%METHANOL COMPATIBLE FRP <br /> ®9 BRONZE ® 10 GALVANIZED STEEL 095 ®99 OTHER <br /> 1 R UNED ®2 ALKYD UNING ®3 EPDXY LINING ❑4 PHENOLIC UNING <br /> C.I G 5 GLASS LINING X 6 UNLINED 95 UNKNOWN <br /> LINING ❑ ❑ <br /> ®IS LINING MATERIAL COMPATIBLE WITH 1 ? YES ®NO ®99 OTHER <br /> D.CORROSION ❑1 Pot. WRAP ®2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGM REIIIFORCED PLASTIC <br /> PROTECTION [:]5 CATHODICTECTION ®91 NONE ®95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYR AM 1 SUCTION A Q 2 PRESSURE A U 3 GRAVITY A,U 9/ NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A a 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 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A 4 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 S 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 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 8 1 VISUALCHECK P,Q 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> PRECISION TESTING P:8 7 PRESSURE TESTING P 8 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 OF3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN BALLOW INERT MATERIAL? ®YES ❑NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF AND THg q6ST MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) I If DATE <br /> e <br /> V1 G. �D <br /> LOCAL AGENCY USE ONLY <br /> V1 171, <br /> FPERMIT <br /> NTY N JURISDICTION# AGENCY# FA LITY 10 A TANK ID M <br /> Lj- no Lo L4 <br /> AGENCY FACILITY 106 APPROVED BY PHONE Y WITH AREA CODE <br /> ev J1454 <br /> MBER MIT VAL OAPERMIT RATION DATE <br /> PERMIT AMOUNT SURCHARGE ANT. FEE CODE 1,,RECE"rr# BY: <br /> FORM s(6-29-88) THIS FORM AF FOR `A', A IR N <br /> DATA P ESSING COPY A <br />