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U 9 ED PROGRAM CONSOLIDATED FORIP PRESUBMITTAL TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Page 3 of 4 TYPE OF ACTION ®1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Chak one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specifyreson-Ibroceluseonly) (Specifyreawn-forloceluseonly) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Sameas FACILITYNAME.DBA-Doing Bmmess As) 3 FACILITY ID: 0 0 0 0 0 0 0 0 0 0 0 Chevron Station#210997 LOCATION WITHIN SITE(opnonep 431 1442 A Colony Drive,Ripon 95366 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 0 No 434 2 XERXES If-Y.,",..plan one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 01/16/2003 15,000 0 ADDITIONAL DESCRIPTION(Far local are only 439 11.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (If markei..,let.Prool.m Type) ®Ib. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER _ ❑3. CHEMICAL PRODUCT COMMON NAME (from Ha endow Materials inventory page) 441 CAS#(from Hazardous Matenab Inventory page) 442 [14. HAZARDOUS WASTE (Includes Usel oil) SUPREME UNLEADED 800-61-9 ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER 095. UNKNOWN M 2. DOUBLE WALL ❑4. SINGLE WALL IN VAULT [199. OTHER TANK MATERIAL-primary trek ❑1. BARE STEEL M3. FIBERGLASS/PLASTIC 05. CONCRETE 095. UNKNOWN 444 (Cheek one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary conk ❑1. BARE STEEL 03. FIBERGLASS/PLASTIC 05. CONCRETE 095. UNKNOWN 445 (Ch.k one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER_ REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑L RUBBER LINED [13.EPDXY LINING [15.GLASS LR41NG ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING M 6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC M 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 449 449 PROTECTION IF APPLICABLE PROTECTION ❑4 BNPRESSED CURRENT ❑99 OTHER (Chak one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chak all that apply) M 1 ALARM Remote ®1 SPILL CONTAINMENT Overfill Audible/Visual Alarm 2003 wJAck Switch ❑3 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE M 2 BALL FLOAT o ❑4 EXEMPT OPW 53VMI,3180 @90% ®3 STRIKER PLATE Tank Mf IV.TANK LEAK DETECTION(A description of the monitoring program shall be submatcd to the tical agency.) IF SINGLE WALL TANK(Check an 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) ❑I 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 ❑S TANK TESTING (SIR) BIENNIAL TANK TESTING El 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) 175 Formerly SWRCB Form B