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U W-PROGRAM CONSOLIDATED FORM l� 01 UNDERGROUND STORAGE TANKS - TANK PAGE 1REsusMITTAI TANKS -( � two pages per tank) TYPEOFACTION ®INEWSIT'E PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFO ❑ 6 TEMPORARY SHE CLOSURE P'a 3.f 4 (Check one hem only) INFORMATION s ❑ 3 RENEWAI'PERMrr (specify ream.-for bol me onl ❑ 7 PERMANENTLY CLOSED ON SITE BUSINESS NAME(some u FACMITY NANM or DBA-wing Busineee o) i (specifynomer-fr tical use°nIY) ❑ 8 TANK REMOVED Chevron Station#210997 3 FACILITY ID: mo LOCATION WITHIN SITE(ominni 0 0 0 0 0 `. 0 0 0 0 0 0 1 1442 A COIOn Drive,Ri On 95366 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST sysuding buildings and lanarks shall be submitted to the local agency.) 431 TANK�p tem incldm 033 TANK MANUFACTURER 2 433 COMPARTMENTALIZED TANK Yes DATE INSTALLED XERXES No 434 (YEAR/MO) m5 TANK CAPACITY IN GALLONS 436 If"Yea",mmplme one page for each mmpmtmenk 01/16/2003 15,000 NUMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION0 437 (For kcal use only 438 TANK USE 439IL TANK CONTENTS PETROLEUM TYPE ®1. MOTOR VEHICLE FUEL (vmarow complain Petroleum Type) 11 la. REGULAR UNLEADED ❑2. LEADED ®16. PREMIUM UNLEADED ❑5. 3FUEL 440 ❑2. NON-FUEL PETROLEUM ❑3. DIESEL ❑6. AVIATION FUEL ❑Ic. MD3GRADE UNLEADED ❑4GASOHOL ASOHOL EI 3. CHEMICAL PRODUCT 1199 OTHER COMMON NAME (ft.Hoomhoe Mmari bmvemory page) 441 CAS# - ❑4. HAZARDOUS WASTE (fiom Hazardous Mareriefs Invemo ry page) 492 (hiUNKNOWN N SUPREME UNLEADED ❑95.UNKNOWN 800-61-9 TYPE OF TANKIII. TANK CONSTRUCTION ❑1. SINGLE WgLL ❑3. SINGLE WALL WITH (Check orc it..only) ❑4. SINGLE WALL IN VAULT ❑99. OTHER EXTERIOR 115. S:5111:LE WALL WITH INTERNAL BLADDER SYSTEM q43 MEMBRANE LINER 1]95. UNKNOWN ®2. DOUBLE WALL TANK MATERIAL-primary uNc ❑1. BARE STEEL ®J. FIBERGLASS 1 PLASTIC ❑5. CONCRETE (Check one hem only) (32. STAINLESS STEEL ❑4. STEEL CLAD W/FHE RGLASS ❑95. UNKNOWN 444 REINFORCED PLASTIC(FRP) ❑S. FRP COMPATIBLE W/100%METHANOL ❑99,OTHER TANK MATERIAL-semndary leak ❑1. HARE STEEL 13. FIBERGLASS/PLASTIC ❑5. CONCRETE (Check one hem only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑95. UNKNOWN 948 ❑ FRACOMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10 10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑].RUBBER LINF,D ❑3.EPDXY LABNG ❑5.GLASS LAIING ❑95.UNKNOWN 496 OR COATING ❑2 ALKYD LINING 4 PHENOLIC EATING ®6 UFILINED DATE INSTALLED 441 (Check one hem only) ❑99 OTHER (Fm bol use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED 44e ❑4IMERESSED CURRENT PLASTIC ❑95 UNKNOWN44g PROTECTION IF APPLICABLE PROTECTION (Cha*orc hem only) ❑2 SACRIFICIAL ANODE 1199 DTHER SPILL AND UVERFI.L YEAR INSTALLED 450 (For bol uu only) TYPE(bol use only) 451 OVER1 1 1 PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chat all that apply) ®1 SPIT.CONTAINMENT ®1 ALARM Remote 2003 Overfill Audible/Visual Alarm w/Ack Switch ❑3 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE N 2 BALL FLOAT 3 STRIKER PLATE Tank MOPW53VML-3180090% ❑4EXEMPT ® f _ IV.TANK LEAK DETECTION(A dela hima of lite mo.irorl.g program shall be wbmind a the tial egencyJ IF SINGLE WALL TANK(Clack.n ma.pply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑]VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING (chat one item only) ❑2 AUTOMATIC TANK GAUGING ATG (3TC) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ATG) ❑6 VADOSE ZONE ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING ❑3 MANUAL MONITORING (SIR) BIENNIAL TANK TESTING 1199 OTHER _ IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 458 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No I (1/99 revised) 175 Formerly SWRCB Form B