COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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STATE OF CALIFORNO WATER RESOURCES CONTRO �:.`�• FORM V: UNDERGROUND STORAGE TANK PROGR NK PERMIT APPLICATION INFORMATION �n�� ' TANK COMPLETE SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR�EAcrjr11* €p'In i NEW PERMIT 3 RENEWAL PERMIT 9?1*5'CHANGE OF INFORM i n 0I I i,5+ I�@E MARK ONLY ❑ �i4 n r� ONE ITEM ❑2 INTERIM PERMIT AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURII�F lUp FACILITY/SITE NAME WHERE TANK IS INSTALLED. Andys Chevron FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID M WC6187C B. MANUFACTURED BY: XERX C.YEAR INSTALLED 1984 D. TANK CAPACITY IN GALLONS: 1,000 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 ❑2 PETROLEUM B. C. 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑X 4 OIL ❑ 1 PRODUCT 4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN EK 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF //� �a� l0�` HAZARDOUS SUBSTANCE STORED&C.A.S.N We cC.A.S.M: 0 -5 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑X 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ i STEEUIRON ❑2 STAINLESS STEEL O 3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RUBBER UNED ❑2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑ LINING 5 GLASS LINING ®6 UNUNED E]95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑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 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 9 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 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A 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 8 100%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 8 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER_ VI. 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? [-]YES F-1NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFP Y,AND T H B T F KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) '0, DATE 1 �/z LOCAL AGENCY USE ONLY E JURISDICTION U AGENCY# FACILITY ID S TANK ID 8 vo -7 & � I 'AGENCY FACILITY ID• APPROVE BY MAA WPHONE 0 WITH AREA CODE TT PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMP A FAcLrffAm MRIQ mom FORM`A',UNLESS A F �A' 0 ' NAS BEEN FILED 1 DATA P ESSING COPY 2 LOA CAL AGENCY CO �COPY