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U*D PROGRAM CONSOLIDATED FORK DWL O PRESUB ITTAL TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 ��9`D!7 (two pages per tank) N/aS P.,I of 4 TYPE OF ACTION ®I NEW SITE PERMIT [14 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE SHIRE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specifyrumn-rorbcalumonly) (Specify reason-for local useonly) ❑ 8 TANKREMOVED 430 BUSINESS NAME(Same.FACILITY NAMEm DBA-Doing Buimas Aa) 3 FACILITY ID: 0 0 Ir;, 0 0 0 0 0 0 0 0 0 1 Chevron Station#210997 LOCATION WITHIN SITE(opti.Q 431 1.TANK DESCRIPTION (A scaled plot pian 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 U Yes N No 434 1 XERXES If-Yea",complete one page far each uaryutm m. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 01/16/2003 20,000 0 ADDITIONAL DESCRIPTION(For bcal.only) 439 1442 A Colony Drive,Ripon 95366 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL ®la. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (if market!complete Petmleom Type) ❑16 PREMIUM UNLEADED [13. DIESEL ❑6. AVIATION FUEL [12. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED [14. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME faom Hawdow MarmiaN lnwomry page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE (Inebaea used Oil) REGULAR UNLEADED 800-61-9 ❑95.UNKNOWN Ill. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (ChedoMhamonly) EXTERIOR MEMBRANE LINER 095. UNKNOWN ®2. DOUBLE WALL [14. SINGLE WALL IN VAULT ❑99. OTHER_ TANK MATERIAL-priory tarec ❑1. BARE STEEL 03. FIBERGLASS/PLASTIC [15. CONCRETE ❑95. UNKNOWN 444 (Check one hem only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑I. BARE STEEL 159 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Clack ane hem only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER_ REINFORCED PLASTIC(FRP) ❑10.COATED STEEL [15- CONCRETE TANK INTERIOR LINING [11.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING M 6 UNLINED ❑99 OTHER (Check oM hem only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN a49 ane PROTECTION IF APPLICABLE PROTECTION [14 MPRIESSED CURRENT ❑99 OTHER (Chetkonehemonly) ❑2 SACRIFICIAL ANODE To bin tae only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(lou,tau only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) N I ALARM Remote - ®1 SPILL CONTAINMENT Overfill Audible/Visual Alarm 2003 w/Ack Switch ❑3 FILL TUBE SHUT OFF VALVE ®2 BALL FLOAT ❑4 EXEMPT ❑2 DROP TUBE OPW 53VML-3180 @90% ®3 STRIKER PLATE Tank Mf _ N.TANK LEAK DETECTION(A description ofthe monitoring program ahall be au6mhted to the local agency.) IF SINGLE WALL TANK(cheek el,wtapply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check oro hem 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 19 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/MODAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 451 gallons ❑Yes ❑ No UPCF(1/99 revised) 173 Formerly SWRCB Form B