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�.. <br /> STATE OF CALIFORN* WATER RESOURCES CONTROLfIARD <br /> FORMV: UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC"TANK. <br /> MARK ONLY t NEWPERMIT 3 RENEWALPERMfT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT RG TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE E WHERE TANK ISI T Knox ' s Texaco Food Mart FARM TANK-YE NO <br /> 1. TANK DESCRIPTIONL I -IF UNKNOWN—80 SPECIFY <br /> A. OWNERS TANK ID N 1 1 B. MANUFACTURED BY: 0 VV ens Corning Tanks' <br /> C.YEAR INSTALLED 1990 D. TANK CAPACITY IN GALLONS: 12 , 0 0 0 <br /> II. TANK CONTENTSI (A.1),IS KED,COMPLETE ITEM C.I (Aah IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM C. t UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN Ej2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZAR US SUBSTANCE STORED a C.A.S.r C.A.S.r: <br /> III. TANK CONSTRUCTIONK ONE ITEM ONLY IN BOX A.9,C.A <br /> I DOUBLE WAUM 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> A.TYPE OF <br /> SYSTEM 2 SINGLE W 4 SEMARY CONTAINMENT N OTHER <br /> I STEELARON 2 STAINLESSSTEEL X 3 FIBERGLASS 4 STEEL CUD WIRBE REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYIANYLCHLORIDE 7 ALUMINUM 8 1 METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> I RU R U 2 LINING 3 EPDXY LINING 4 PHE LINING <br /> C.INTERIOR <br /> LINING 5 GLASS LINING 6 UNLINED 95 mom <br /> IS LINING MATERIAL COMPATIBLE WITH t ? X YES NO N OTHER F:.jbo-rr-Q mcc TnnLe <br /> D.CORROSION El 1 POLYMUNE WRAP 1 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED KAM <br /> PROTECTION5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> JIV. PIPINGINFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A,SYSTEM TYPE A U 1 SUCTION A �2PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHERCO A U 1 SINGLE WALLED A LE WALLED A U 3 LINED TRENCH A 10­91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U l STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.NATERK A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 1 METHANOL COMPATIBLE FRP <br /> 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 SYSTEMUST BE CIRCLED. <br /> FP f 1 VISUAL CHECK `f 2 INVENTORY RECONCILIATION P 3 VADOSE WELLP f 4 ELECTRONIC MONITORP f 5 GROUND WATER MONITORING WELLS <br /> P f 6 PRECISION TESTING P 7 PRESSURE TESTING P f 91 NONE P 8 95 UNKNOWN P f 99 OTHER <br /> I. INFORMATION IN PLACE <br /> t.ESTIMATED DATE LAST USED(MOlYR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? YES NO <br /> THUS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> =APPLICANT'JS (PRINTED 8 SIG E) �aKnox d <br /> LOCAL AGENCY USE ONLY <br /> f <br /> COJURISDICTION A CY f " <br /> .. <br /> UNT <br /> T KID <br /> APPROVED NE• v <br /> CODE IDCURRE PERMIT ov DA rt DATE <br /> u C I • Y: <br /> f M O(6-29 ) THIS FORM MW K AFmammummuTm FORM' , 'A' IMISBEENFILED ' <br /> 1 Y <br />