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U"�D PROGRAM CONSOLIDATED FORM PRESUBMITTAL TANKS UNDERGROUND STORAGE TANKS - T K PAGE 1 (two pages per tank) e of a TYPE OF AMON ®1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Chock me item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Spo6fyrmsm-fal0oaIwcmly) (Sp ifyreesoo-fotlocaweonly) ❑ 8 TANK REMOVED 46 BUSINESS NAME(Same®FACadrYNAmEmDBA-Doing Business As) 3 FACILITY ID: 0 0 0 0 0 0 0 0 0 0 0 l Chevron Station#210997 LOCATION WITHIN SITE(optional) 431 Hwy 99&Colony Drive,Ripon CA 95366 L 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 435 COMPARTMENTALIZED TANK ❑Yes ® No 434 2 XERXE.S If"Yet',co oplae one page for each comps u tent DATE INSTALLED(YEARIMO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 Target Install 7/l/02 15,000 0 ADDITIONAL DESCRIPTION(For lora).only 439 II.TANK CONTENTS 5 . TANK USE 459 PETROLEUM TYPE eeo T Aft ®1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifmmkedeompl.Pooulmm Type) ® Ib. PREMIUM UNLEADED ❑3. DIESEL (3 6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER_ 03. CHEMICAL PRODUCT COMMON NAME (Iran Hma&. Materials lnvmmry page) 441 CAS#(from Hamrdous Mate6als lnrmwsy page) 442 ❑4. HAZARDOUS WASTE (IncladesDsmoip SUPREME UNLEADED 800-61-9 95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL ❑3. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER [195. UNKNOWN ®2. DOUBLE WALL [14. SINGLE WALL IN VAULT ❑99. OTHER_ TANK MATERIAL-pdmary reek ❑1. BARE STEEL ®3. FIBERGLASS/PLASTIC 05. CONCRETE ❑95. UNKNOWN 444 (Chock..itemonly) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL [199.OTHER_ REINFORCED PLASTIC(FRP) TANK MATERIAL-xcondary rank ❑ 1. BARE STEEL ®3. FIBERGLASS/PLASTIC S. CONCRETE 095. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL C14. STEEL CLAD W/FBERGLASS E18. FRP COMPATIBLE W/100%METHANOL ❑99.O'T'HER REINFORCED PLASTIC(FRP) [1 10.COATED STEEL ❑S. CONCRETE TANK INTERIOR LINING ❑t.RUBBER LINED ❑3.EPDXY LINING ❑S.GLASS LINING 1195.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING R 6 UNLINED ❑99 OTHER (Chock one item only) IF.,local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC (9 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 448 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT Cl 99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(loml use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ®I SPILL CONTAINMENT (9 1 ALARM Remote 2002 Overfill AudibleNisual Alarm ❑3 FILL TUBE SHUT OFF VALVE ❑2 DROP TUBE ®2 BALL FLOAT ❑4 EXEMPT OPW 53VML-3180 ®3 STRIKER PLATE Tank Mfg _ N.TANK LEAK DETECTION(A description ofine monitoring progomn shall be suhmium m me local ag.oy.) IF SINGLE WALL TANK(Chock all mat apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Chock me item 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 ❑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 N.TANK CLOSURE INFORMATION J PERMANENT CLOSURE IN PLACE EMWAT ED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 056 TANK FILLED WITH INERT MATERIAL? 451 gallons []Yes ❑ No UPCF(1/99 revised) 175 Formerly SWRCB Form B