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D PROGRAM CONSOLIDATED FOIJ PRESUBMF1'I'AL TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) P e'1 4 TYPE OF AMON R 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT [35 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE \ l.� (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE C13 RENEWAL PERMIT (speci%ras eon-forinedosawly) (Specilyreuon-forkom nalonly) C] STANK REMOVED o BUSINESS NAME(Sameas FACRMNAMEor DBA-Doing Business As) 3 FACILITY ID: 0 0 0 0 0 - 0 0 0 0 0 off Chevron Station#210997 R° LOCATION WITHIN SITE(Optional) 431 I.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"Yes",complete one page for each compamnrnt. DATE INSTALLED(YEAR/MO) 415 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 Target Install 7/l/02 20,000 0 ADDITIONAL DESCRIPTION(Fm local use only) 438 Hwy 99&Colony Drive,Ripon CA 95366 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL ®la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifinerked complete Peackem Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL [12. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER_ 03. CHEMICAL PRODUCT COMMON NAME (front award. Mazenials I--any page) 441 CAS#(from Brocade.Materials inventory page) 442 ❑4. HAZARDOUS WASTE (Inemdes Used Oil) REGULAR 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 ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SINGLE WALL IN VAULT ❑99. OTHER_ TANK MATERIAL-primary tank ❑1. BARESTEEL ®3. FIBERGLASS/PLASTIC S. CONCRETE 095. UNKNOWN 444 (Checkonc item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FE3ERGLASS ❑S. FRP COMPATIBLE W/100516 METHANOL [199-OTHER_ REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑1. BARE STEEL 9 3. FIBERGLASS/PLASTIC ❑S. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING [195.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LTMNG ®6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑I MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN a48 448 PROTEMON IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For loan[we only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local we only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Checkdl thaz apply) ®ISPn.L CONTAINMENT NI 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 IV.TANK LEAK DETECTION(A description ofthe monitoring prognam shall be submined to the local 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 MATERIAL? 457 gallons ❑Yes ❑ No UPCF(1/99 revised) 173 Formerly SWRCB Form B