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U ED PROGRAM CONSOLIDATED FOR119 PRESUBMITTAL TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page 1 of 4 TYPE OF ACTION ®1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Speclfyrauon-forkceluseonly) (Specifyrtason-Porbcalueemly) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 1 Chevron Station#210997 FACILITY ID: 0 0 0 0 0 0 0 0 0 0 0 LOCATION WITHIN SITE(opkawa 431 1.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 XERXES If"Yea',complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 01/16/2003 20,000 0 ADDITIONAL DESCRIPTION(For local use only) 439 1442 A Colony Drive,Ripon 95366 11.TANK CONTENTS TANKUSE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL ®la. REGULAR UNLEADED ❑2. LEADED [IS. JET FUEL (If marked complete Pclmleum Type) ❑Ib. PREMIUM UNLEADED ❑3. DIESEL [16. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑1 c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER [13. CHEMICAL PRODUCT COMMON NAME (tram Hazardous Materials Invemory page) 41I CAS#(from Hazardow Materials Inventory page) 442 ❑4. HAZARDOUS WASTE (mcbdeaUsed Oil) REGULAR UNLEADED 800-61-9 ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WAIL WITH [15- SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR ME VIBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SINGLE WALL IN VAULT [199. OTHER TANK MATERIAL-primary tank [11. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑5. CONCRETE 095. UNKNOWN 444 (Checkwo itemonly) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Check oM dem only) ❑2. STAINLESS STEEL E14. STEEL CLAD W/FBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) [110.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED [13.EPDXY LINING ❑5.GLASS LINING [195.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one hem only) (For kcal use only) OTHER CORROSION - ❑1 MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN a9 a49 PROTECTION IF APPLICABLE PROTECTION [14 11APRESSED CURRENT ❑99 OTHER (CheckoMaemonly) ❑2 SACRIFICIAL ANODE (For bin use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local we only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chak all that apply) ®1 ALARM Remote ®1 SPILL CONTAINMENT Overfill AudiblelVisual Alarm 2003 w/Ack Switch ❑3 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE ®2 BALL FLOAT ❑4 EXEMPT OP W 53 V ML-3180 @90% ®3 STRIKER PLATE Tank Mf _ IV.TANK LEAK DETECTION(A description ofthe monitoring program shall be submitted to the bcnl agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ®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 MATEIi 457 gallons ❑Yes ❑ No UPCF(1/99 revised) 173 Formerly SWRCB Form B