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'IFIED PROGRAM CONSOLIDATED FO- I N%.� J TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page 1 of 8 TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT N 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (SPaifyreawn-fmlocalmecnly) (Spacityreason-focbcalaaeonly) ❑ 8 TANK REMOVED 430 BUSINESS NAME(S.at,FAMTY NAME«DBA-Doing Bminess As) 3 FACILITY ID: O O 11 1 0 0 0 0 0 0 0 0 O 1 Chevron Station#90557 LOCATION WITHIN SITE toptiona0 431 139 S Center St.,Stockton,CA 95202 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# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes No 434 1 JOOR If"Yes",complete one page far each compannent. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1/1/90 10,000 0 ADDITIONAL DESCRIPTION(For tical use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE aaa N 1. MOTOR VEHICLE FUEL N la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL nf.lmdcmryMe Peuokum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL [16. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER_ ❑3. CHEMICAL PRODUCT COMMON NAME (from Baomiom Mazeriale lnv<ntorypage) 461 CAS#(from Hazardous Materials Invmtory page) 442 ❑4. HAZARDOUS WASTE (IncludeaUaedml) REGULAR UNLEADED 800-61-9 ❑95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH 0 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check ms nem only) EXTERIOR MEMBRANE LINER 095. UNKNOWN 02. DOUBLE WALL ❑4. SINGLE WALL IN VAULT [199. OTHER TANK MATERIAL-primary tank 01. BARE STEEL 03. FIBERGLASS/PLASTIC 05. CONCRETE 095. UNKNOWN 444 (C k one dem only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tvik ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC [15. CONCRETE ❑95. UNKNOWN 445 (Check one nem only) ❑2. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER_ REINFORCED PLASTIC(FRP) ❑10.COATED STEEL [15. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LD41NO N 6 UNLINED ❑99 OTHER (Check.item only) (Fm local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC N 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN "s "a PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (Fmbcalueeonly) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE noml me only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chet],all that apply) N 3 FILL TUBE SHUT OFF VALVE N I SPILL CONTAINMENT 1990 N 1 ALARM OPW 61-SO4 ®2 DROP TUBE 1998 OPW 61-SO-4 ❑2 BALL FLOAT _ ❑4 EXEMPT ®3 STRIKER PLATE Tank Mf _ W.TANK LEAK DETECTION(A description ofthe monitoring program shall be submitted to the kcal agency) IF SINGLE WALL TANK(check all that apply) 053 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE N 2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(1/99 revised) L 173 4.! Formerly SWRCB Form B