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UNIFIED PROGRAM CONSOLIDATED FO1 <br /> V TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE'. p'7 <br /> l0)39� (tlwpages per tank) <br /> Page _ of _ <br /> TYPEOFACTION ❑1.NEW SITE PERMIT ❑ 4.AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check one item only) El T. PERMANENTLYCLOSED ON SITE <br /> X 3.RENEWAL PERMIT (SPaclrY reason-brkcal use mly) (Spsrly change-lorkxal use only) <br /> ❑ 8. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME o DBA-Doing Business As) FACILITY ID Y 1 <br /> Safeway Inc,Fuel Station 1769-10 <br /> LOCATION WITHIN SITE(Optional) 431 <br /> I.TANK DESCRIPTION <br /> TANK 10 If .r TANK MANUFACTURER COMPARTMEMALIZED TANK % Yes ❑ Na <br /> 2a \ l Os + ` SS MoOem Welgn9 If Wes',complete one Page for each companment. <br /> DATE INSTALLED(YEARNED)2W1.July TANKCAPAClW IN GALLONS 10,000 NUMBER OF COMPARTMENTS ; <br /> Z <br /> ADDITIONAL DESCRIPTION(Folocal use only) <br /> II.TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> X MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL <br /> ma'WI complete Petroleum Type) X h. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATIONFUEL <br /> ❑ 2. NON-FUEL PETROLEUM 1c. MIDGRADEUNLEADED ❑ 4. GASOHOL El se. OTHER <br /> ❑ 3. CHEMICAL PRODUCT <br /> ❑ 4. HAZARDOUS WASTE(InGurfes COMMON NAME(from Hamftus Materials fmanloypage) CAS p(hon/lazanbus Materials Invenlay papa) <br /> Usatl 011) GaWine 800661-9 <br /> ❑95. UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ` ❑ 1. SINGLEWAIL ❑ 3. SINGLEWALLWITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM <br /> (Check one Item only) 1 2. DOUBLEWALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN <br /> v ❑ 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL-primary tank, 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE 1195. UNKNOWN <br /> (Check one Rem any) 2. STAINLESSSTEEL ❑4. STEEL CLAD WIFISERGLASS ❑ 8. FRP COMPATIBLE W/100%METHANOL 1199. OTHER <br /> REINFORCED PLASTIC FRP <br /> TANK MATERIAL-seconUary lank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC J ❑ 8. FRP COMPATIBLE W1100%METHANOL 095. UNKNOWN <br /> (Check ane ttem only) ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS /�/�X!�. FRP NON-CORRODIBLE JACKET 1199, OTHER <br /> REINFORCED PLASTIC(FRP) LJ 10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR UNING ❑ 1. RUBBERLINED ❑ 3. EPDX UNWG ❑ S. GLASS LINING ❑95. UNKNOWWM DATEINSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED ❑99. OTHER <br /> Check are kem an Fabcal use <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC 133. FIBERGLASS REINFORCED PLASTIC 1195. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> 13 4. IMPRESSED CURRENT El 99. OTHER <br /> (Check acre Item only) ❑ 2. SACRIFICWL ANODE (Twbral use only) <br /> SPILLANDOVERFILL \ YEAR INSTALLED TYPE(Fo local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all Nat apply) <br /> SPILLCOMAINMENT 2001 . ALARM 2001_k3. FILL TUBE SHUT OFF VALVE <br /> 2. DROP TUBE 2001 1 <br /> 2. BALL FLOAT 2001_ 134. EXEMPT <br /> 1 X 3. STRIKER PLATE 2001 <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all that apply): IF DOUBLE WALL TANK OR TANK WITH BLADOER(Check one Item only: <br /> ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) 1 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE X 2. CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ T. GROUNDWATER 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR) ❑ 8. TANKTESTING <br /> BIENNIAL TANK TESTING ❑9g, OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? <br /> oalione ❑Yes ❑No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />