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IFIED PROGRAM CONSOLIDATED FORK TANK: TA0101401 PR #: PR0231014 UNDERGROUND STORAGE TANKS - TANK PAGE 1 FAC #: FA0003777 (two pages per tank) TYPE OF ACTION Page 2 of 3 ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check only item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT ❑ 8 TANK REMOVED 430 BUSINESS NAME (Same as FACILfI'Y NAME or DBA -Doing Business As) FACILITY ID: PR #: 1 TOYS R US 3 FA0003777 PR0231014 LOCATION WITHIN SITE (optional) 1624 ARMY CT, STOCKTON 431 PHONE I. TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# Tank #: 1 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑ Yes XNo 434 TA0101401 If "Yes", complete one page for each compartmrnt. DATE INSTALLED (YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 10,000 ADDITIONAL DESCRIPTION (For local use only) 438 3/06/00 CHNG PE FR 2330 TO 2360 PER MK. LBR II. TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® I. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked complete Petroleum Type) ❑ Ib. PREMIUM UNLEADED ® 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ 1 c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Haurdous Materials Inventory page) 441 CAS# (from Hazardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 441 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN ® 2. DOUBLE WALL ❑ 4. SINGLE WALL IN VAULT ❑ 99. OTHER TANK MATERIAL - primary tank ® 1. BARE STEEL ❑ FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN (Check one item only) ❑ 2. STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/ 100% METHANOL REINFORCED PLASTIC (FRP) ❑ 99. OTHER TANK MATERIAL - secondary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTI BILE W/100% METHANOL REINFORCED PLASTIC (FRP) ® 10. COATED STEEL ❑ 99. OTHER ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ S. GLASS LINING ❑ 95. UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑ 99. OTHER (Check one item only) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ® 6 UNLINED (For local use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER (Check one item only) ® 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE (local use only) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 ® I SPILL CONTAINMENT 1,987.00 (Check all that apply) Y1 A 1- ®I ALARM 2,000.00 3 FILL TUBE SHUT OFF VAL MY 2 DROP TUBE 1,987.00 -}u� ❑ 4 EXEMPT 2 BALL ❑X 3 STRIKER PLATE 1,987.00 FLOAT IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the Iota) agency.) IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ SUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING (MTG) El (Check one item only) TANK GAUGING (ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL (SINGLE WALL IN VAULT ONLY) [[[[[[ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ® 2 CONTINUOUS INTERSTITIAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑ 3 MANUAL, MONITORING (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) a55 ESTIMATED QUANTITY OF SUBSTANCE REMAINING a56 TANK FILLED WITH INERT MATERIAL? 457 ❑ Yes ❑ No UPCF (12/99 revised)