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STATE OF CALIFORNS WATER RESOURCES CONTRO46ARD <br /> FORMV: UNDERGROUND STORAGE TANK PROGRAMTANK COMPLETE A SEPARATE w- <br /> TANK PERMIT APPLICATION INFORMATION <br /> ® , - <br /> FORM WITH THE FOLLOWINGINFORMATION <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE E WHERE TANK IS INST - Knox ' s Texaco Food Mart FARM TANK-YENO <br /> 1. TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN—30 SPECIFY <br /> A. <br /> STANK ID• 2 B. MANUFACTURED BY: Ougoa Corning Tanks <br /> C.YEAR INSTALLED 1990 O. TANK CAPACITY IN GALLONS: 12 . 000 <br /> IL TANK CONTENTS IF(A.1),Is MARKED,COMPLETE C.IF(A.1),Is NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. <br /> C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL ' PRODUCT 4 GASOHOL 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.•: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA.9,C.A <br /> A TYPE OF 1 ABLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER El 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED l SECONDARf CONTAINMENT N OTHER <br /> I STEELRRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGM REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 1 PATIBLE FRP <br /> MATERIAL9 BRONZE 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER <br /> 1RUBBER LINED 2 UNING 3 EPDXY LINING 4 RIE LINING <br /> C. RIO <br /> LINING 5 GLASS LINING 6 UNLINED 95 MNOWN <br /> IS LINING MATERIAL COMPATIBLE wrrm, ? YES No 99 OTHER Fiberglass Tan k <br /> 0.COMOSION 1 POLYETHLENE WRAP 2 TAR OR APHALT 3 VINYL WRAP 4 FIKAGLASS REINFORCED KAM <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> PIPINGINFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> .CO 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 STEEL/IRON 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 U 8 1 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTIONCIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM UST BE CIRCLED. <br /> EstVISUAL CHECK P 2 INVENTORY RECONCILIATION P f�VE WELLS P f 4 ELEC IC ITOR �659GRDUNDWA�TERMONIT�ORINGV <br /> 6 PRECISION TESTING P f 7 PRESSURE TESTING ► f P 95 UNKN OHER <br /> I. INFORMATI ON ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE L77= <br /> 2.ESTIMATED QUANTITY OF 3.WAS TANK FELLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATU ) DATE <br /> on <br /> Chris Knox �t <br /> LOCAL AGENCY USE L <br /> CU JURISDICTION• AGENCY• £1 TANK ID• <br /> CURRENTLOCAL A CY FACI 10• APPR PHONE•WITH AREA CODE <br /> s <br /> RPERMIT APPROVAL DATE PERMIT 01PIRATIO10 DATE <br /> pp <br /> 0,, CHECK• PERMIT AMOUNT SURCHARGEC • BY: ' <br /> FORM 8(6-29- ) TM FNM MW K 11 ® !, A IN D <br /> 1 Y <br />