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STATE OF CALIFORA <br /> WATER RESOURCES CON ARD <br /> FORMV: UNDERGROUND STORAGETANK PROGRAM #94275A <br /> TANKT I I TI F I ' <br /> COMPLETE A SEPARATE FORM I E FLLO '31 INFOR TION FOR CH TANK. `� •�>�' <br /> K ONLY ❑1 NEW PERMIT 3 RENEWAL PERMIT 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ®2 INTERIM PERMIT 4 AMENDED IT ❑ 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK Is INSTALLED: Lincoln Vill2ge Wes VT,01A 4aaa FARM TANK-YES® NO <br /> I. TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN—90 SIPECiI <b <br /> A. OWNERS TANK ID# 715852 B. FILM L I I IOVVDT <br /> C.YEAR INSTALLED 1984 D. TANK A I A 12,000 a.11onS <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. QX 1 MOTOR VEHICLE FUEL ®2 PETROLEUM B. C. ❑1 UNLEADED ®2 LEADED ®3 DIESEL <br /> ®3 CHEMICAL PRODUCT ®4 OIL i CT ®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.#: 1 <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,s D <br /> A OF F-X�i DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ®2 SINGLE WALLED ®4 SECONDARY CONTAINMENT ®99 OTHER <br /> ® 1 STEEL/IRON ®2 STAINLESSSTEEL ®3 FIBERGLASS ®4 STEELCAD W/FlBERGIASSREINFORCEDPLASTIC <br /> B.TANK ®5 CONCRETE ®6 POLYVINYL CHLORIDE ®7 ALUMINUM ®B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE ®10 GALVANIZED STEEL ®95 UNKNOWN ®99 OTHER <br /> ®1 RUBBER LINED ®2 ALKYD LINING ®3 EPDXY LINING ®4 PHENOLIC LINING <br /> C.INMRIOR <br /> LINING Q 5 GLASS LINING ❑6 UNLINED ®95 UNKNOWN <br /> ®IS LINING MATERIAL COMPATIBLE WITH 1 L? ®YES ®NO 99 OTHER <br /> .CORROSION 1 POLYETHLE14E WRAP 2 TARORASPHALT 3 VINYL WRAP 4 FIBEMLASS REINFORCED PLASTIC <br /> PROTECTION ®5 CATHODIC PROTECTION ®91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF AMICABLE <br /> 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 <br /> K B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A U 95 UNKNOWN A U .99 OTHER <br /> A U 1 STEELPRON 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 S 1 VISUAL CHECK P iZ 2 INVENTORY RECONCILIATION PS 3 VADOSE WELLS 0)8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P'E 91 NONE P E 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 OUANT17Y OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING W GALLONS INERT MATERIAL? [:]YES ❑NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL OF URY, D T E ES F KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> YR O <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# F ITY ID# TANK ID# <br /> E Li I I / <br /> CURRENT LOCAL AGENCY FACILITY ID APPROVED BY E NE# AREA CODE PpVf <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT IDIPIRATION DATE <br /> I I k 10 <br /> CHECK# PERMIT SURCHARGE AMT.- FEE RLEI IPT• ®Y: <br /> A I I L <br /> FORM 8(6-29-e8) THIS FORM FOR `A', A -A° MSMIIFUD <br /> 1 DATA PRO ING COPY 2 UWAL AGENCY Com 3ftl COPY <br />