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UNIFIED PROGRAM CONSOLIDATED FO D (013t)IITANKS UNDERGROUND STORAGE TANKS -TANK PAGE2U(Z (taro pages per tank) Pape _ of TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 8. TEMPORARY SITE CLOSURE (Check one Item only) 11 7. PERMANENTLY CLOSED ON SITE X 3.RENEWAL PERMIT (SpeGba resonrd-Iorbuse pMy) (Spedly Glanpe-fw local use only) ❑ B. TANK REMOVED 430 BUSINESS NAME(Same a5 FACILITY NAME or DBA-Doing Business As) FACILITY ID# 1 Safeway Inc,Fuel Station 1769-10 LOCATION WITHIN SITE(Opllorcep 431 I.TANK DESCRIPTION TANK ID# TANK MANUFACTURER 1 OS 15S. Modem Welding COMPARTMEt'YWw EDTANK EI r No If ,complete we page for each mparMenl. DATE INSTALLED(YEARIMO)2001,July TANK CAPACITY IN GALLONS 20,000 NUMBER OF COMPARTMENTS 1 ADDITIONAL DESCRIPTION(For local use only) II.TANK CONTENTS TANK USE 432 PETROLEUM TYPE X 1. MOTOR VEHICLE FUEL XIa. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (If marked,complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑99. OTHER ❑ 3. CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(InclWes COMMON NAME(from Haurdous Maledals Inuenrory pope) CAS#(from Hazardous Materials Im,antory page) Used 011) Gasoline 800661-9 El 95. UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLEWALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) X 2. DOUBLEWALL EXTERIOR MEMBRANE LINER El o. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑M. OTHER TANK MATERIAL-primary lank X 1. BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 1195. UNKNOWN (Check.fican ww ❑ 2. STAINLESS STEEL ❑4. STEELCLADWIFIBERGUVSS ❑ 8. FRPOOMPATIBLEW/100%METHANOL 13 99, OTHER REINFORCED PLASTIC FRP TANK MATERIAL-secondary tank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 8. FRP COMPATIBLE W/1 00%METHANOL 13 95. UNKNOWN (Check one Item only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD WIFIBERGLASSFRP NON-CORRODIBLE JACKET 099. OTHER REINFORCED PLASTIC(FRP) 10. COATED STEEL ❑ 5. CONCRETE TANK INTERIOR LINING COATING 1. RUBBER LINED ❑ 13 ❑ 43 ❑ 3. EPDXY LINING 5. GLASS LINING 95. UNKNOWN3 DATE INSTALLED TA ❑ 2. ALKYD LINING 134. PHENOLIC LINING ❑ 6. UNLINED El N. OTHER Check are#em onl Fwklcal use on1 OTHERCORROSION ❑ 1. MANUFACTURED CATHODIC 11 3. 95 3. FIBERGLASS REINFORCED PLASTIC ❑ . UNKNOWN <W DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION 11 4. IMPRESSEDCURRENT ❑99. OTHER (Check are i2m only) ❑ 2. SACRIFICIAL ANODE (Fw kxal use oNy) SPILL AND OVERFILL YEAR INSTALLED TYPE(Fwlocal use wlW OVERFILL PROTECTION EQ U IPMENT:YEAR INSTALLED (Check all thal apply) X 1. SPILL CONTAINMENT 2001 / W 1 ✓ X 1. ALARM 2001 3. FILL TUBE SHUT OFF VALVE % 2. DROPTUBE 2001 X 2. BALL FLOAT 2001 ❑ 4. EXEMPT X 3. STRIKER PLATE 2001 IV. TANK LEAK DETECTION IF SINGLE WALL TANK(Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BUDDER(Check we Item only): ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MITE) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2. AUTOMATICTANKGAUGING(ATG) ❑ 6. VADOSEZONE X 2. CONnNUOUSINTERSTITIALMONITORING ❑ 3. OONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUALMONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. TANKTESTING BIENNIAL TANK TESTING ❑99. OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRrtAOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 1 TANK FILLED WITH INERT MATERIAL? nallons ❑Yes ❑No CUPAFORM(4/99) Formerly SWRCB Form B