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STATE OF CALIFORN* WATER RESOURCES CONTROKIARD <br /> FORMV: UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE <br /> FOLLOWING l F �•,,,a:�.. <br /> MARK LY PM IT <br /> I IREMT 4EN T 66 TEM TANK CL 8 TANK REMOVED <br /> 3 RENEWAL R 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED NK <br /> [E:j ONE ITEM FACILITY/SITE WHERE TANK ist sT . Knox ' s Texaco Food Mart FARM TANK- S NO <br /> . TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN—80 SPECIFY <br /> A. OWNERS TANK ID M 3 B. MANUFACTURED BY: Owens Cornin Tanks <br /> C.YEAR INSTALLED 1990 D. TANK CAPACITY IN GALLONS: 12 , 000 <br /> II. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITENI C.I (A.1),Is NOT MARKED,COMPLETE ITEM D. <br /> A. t MOTOR VEHICLE FUEL 2 PETROLEUM B. C. t UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL , 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 b C.A.S.M C.A.S.N: <br /> Ill. TANK CONSTRUCTIONK ONE ITEM ONLY IN BOX A.B.C.A <br /> A F t DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 LINKNOWN <br /> SYSTEM2 SINGLE WALLED t SECONDARY CONTAINMENT 99 OTHER <br /> I STEELARON 2 STAINLESS STEEL 3 FIBERGIMS <STEEL CLAD W/FIBERGM REINFMCED KWIC <br /> B.TMK 5CONCRETE6 POLYVINYL CHLORIDE 7 ALUMINUM 8 t PATIBLE FRP <br /> MATERIAL 9 BRONZE 10 GALVANIZED STEEL UNKNOWN N OTHER <br /> 1 R U 2 LINING 3 EPDXY UNING 4 PHENOLICLINING <br /> UNING C 1 IR 5 GLASS LINING 6 UNLINED 95 UWNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 1 ? EZ YES NO X OTHER <br /> Fiberglass Tank <br /> D.CORROSION 1 POLYETHLENEWRAP 2 TAR OR ASPHALT 3VINYL WRAP 0 4 FIBERGLASS REINFORCED WTIC <br /> PROTECTION5 CATHODIC PROTECTION 91 NONE 95 99 OTHER <br /> IV. `PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF AMICABLE <br /> A.SYSTEM A U t SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONTRUCTION 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 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 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 08 t 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 /> f t VISUAL CHECK 2 INVENTORY RECONCILIATION P f 3 NADOSE WELLS s 4 ELECT IC MONK P 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P f 7 PRESSURE TESTING P f 91 NONE 95 UNKNOWN P f 99 OTHER <br /> . INFORMATION IN PLACE <br /> t.ESTIMATED DATE LAST USED(MO/YR)- <br /> 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALL9NIEINERT MATERIAL? YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 6 SIGNA RE) DATE <br /> Chris Knox <br /> LOCAL Y,USE ONLY <br /> COUNTY# JURISDICTION M AGENCY# LITY ID 0 TANK I <br /> R L Y FACILITY ID f PHONEfWfTH AREA CODE <br /> PERMIT NUMBER PERMrr APPROVAL DATE PERMIIT EXPIRATION DATEo <br /> 0A CHECK f PERUff AMOUNT SURCHARGE ----] 1 f ay: <br /> F e(6.29 ) THISFOWNWEACCOW STAFAmmmummmii, FORM® ', <br /> 03iCESSIO4000PY <br />