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D PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANKS _ TANK PAGE 1 ES�TT414�S T/10��5�07 (two pages per tank) TYPE OF ACTION ®1 NEW SITE PERMIT [1 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION [3 6 TEMPORARY SITE CLOSURE a of 4 (Check one item only) 1 ❑ 3 RENEWAL PERMIT (Specif reason- -�- 0 7 PERMANENTLY CLOSED ON SIT BUSINESS NAME is.,a9 FACILITY NAME ar DBA- Y for loceluseonly) (Sptrafyreason-forlocalasemly) [1 8TANK REMOVED 01 11II/A' Going Business AH) 41 1 Chevron Station#210997 3 FACILITY ID: 0 01 LOCATION WITHIN SITE(optional) 0 0 0 0 0 0 0 0 0 Hwy 99&Colony Drive, on CA 95366 431 L TANK DESCRIPTION (A scaled plot plan Wi[h he location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 2 431 COMPARTMENTALIZED TANK 0 Yes ® Na DATE INSTALLED(YEAR/MO 435 XERXES 414 TANK Target Install 7/1/02 15,000 CAPACITY IN GALLONS 036 If Yea'complae one page for each comportment NUMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION(Forlocol mec 0 437 439 TANK USE q19 TROM II.TANK CONTENTS PELEUTYPE ® 1. MOTOR VEHICLE FUEL ❑N. REGULAR UNLEADED 2. LEADED 44o (Ifmarked mmplae Petroleum Type) ❑5. JET FUEL ❑2. NON-FUEL PETROLEUM ®Ib. PREMIUM UNLEADED 0 3. DIESEL O 6. AVIATION FUEL ❑3. CHEMICAL PRODUCT 0 to. MIDGRADE UNLEADED Q4. GASOHOL 099.OTHER_ [34. HA7ARDOUS WASTE COMMON NAME (from Haaardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 (Includes Uaed oil) SUPREME UNLEADED ❑95.UNKNOWN 800-61-9 TYPE OF TANK III. TANK CONSTRUCTION ❑1. SINGLE WALL �3. SINGLE WALL WITH (Check one item only) ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 EXTERIOR MEMBRANE LINER ❑95. UNKNOWN only) no TANK MAT 02. DOUBLE WALL [14. SINGLE WALL IN VAULT 0 99. OTHER_ primary tank -7, BARE STEEL ®3. FIBERGLASS/PLASTIC (Check one i.only) El 2. STAINLESS STEEL ❑5. CONCRETE 0 95 UNKNOWN 444 ❑4. STEEL CLAD W/FIBERGLASS 0 8. FRP COMPATIBLE W/100%METHANOL 0 99.OTHER_ REINFORCED PLASTIC(FRP) TANK MATERIAL-semndary lank � 1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑5. CONCRETE (Check oneitum°nly) 02. STAINLESS STEEL 04. STEEL CLAD W/FBERGLASS �95• UNKNOWN 445 [18. FRP COMPATIBLE W/100%METHANOL 0 99.OTHER REINFORCED PLASTIC(FRP) [I 10.COATED STEEL TANK INTERIOR LINING ❑5. CONCRETE ❑1.RUBBER LINED U 3.EPDXY LINING �5.GLASS LINING OR COATING1-195.UNKNOWN 446 DATEINSTALLED 447 (Check one itan only) ❑2 ALKYD LINING [1 4 PHENOLIC LINING ® UNLINED 6 ❑99 OTHER OTHER CORROSION 1 MANUFACTURED (For local use only) CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC 0 95 UNKNOWN 448 PROTECTION IF APPLICABLE PROTECTION 448 (Check one item only) 0 2 SACRIFICIAL ANODE 4IMPRESSED CURRENT 1199 OTHER SPILL AND OVERFILL YEAR INSTALLED 450 (For local use only) (Check all that apply) TYPE(IoW use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 ® I SPILL CONTAINMENT 2002 ®1 ALARM Remote Overfill Audible/Visual Alarm El 3 FILL TUBE SHUT OFF VALVE 2 DROP TUBE ®2 BALL FLOAT DPW 53VML-3180 04 EXEMPT ®3 STRIKER PLATE Tank Mfg _ IV.TANK LEAK DETECTION(A dumonon of We monitoring program shall be suto fie local agenry.) IF SINGLE WALL TANK(Check all that apply) bminM 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑1 VISUAL(EXPOSED PORTION ONLY) [1 5 MANUAL TANK GAUGING TG (Clawk me item only) ❑2 AUTOMATIC TANK GAUGING(ATG) ) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑6 VADOSE ZONE 02 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER 3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION [1 8 TANK TESTING (SIR) BIENNIAL TANK TESTING [1 99 OTHER _ IV.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTTMATED DATE LAST USED(YR/MO/DAY) 455 ESTENATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons Ej Yes [I No UPCF(1/99 revised) 175 Formerly SWRCB Form B