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UNIFIED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE $ ' <br /> rD <br /> (fvro pages per tank) <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT ❑ 5. CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE <br /> (Check ale Item only) ❑ 7. PERMANENTLY CLOSED ON SITE <br /> X 3.RENEWAL PERMIT (Spaufy reason-/wbcal.only) (Specifyrhalpe-lorbral use wly) <br /> ❑ B. TANK REMOVED 430 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID <br /> Safeway Inc,Fuel Station 1769-10 <br /> LOCATION WITHIN SITE(Op(laral) 431 <br /> 1.TANK DESCRIPTION <br /> TANK ID TANK MANUFACTURER <br /> 3 "i��k Q �C <br /> Madan Welding COMPARTMENTALIZED TANK Yes % NO <br /> If-Yes",wmplete one page br ch compatlment. <br /> DATE INSTALLED(YEARVMO)2001,July TANK CAPACITY IN GALLONS 10,000 NUMBER OF COMPARTMENTS�L <br /> 2 <br /> ADDITIONAL DESCRIPTION(Forbcal use only) <br /> 1 IL TANK CONTENTS <br /> TANK USE 432 PETROLEUM TYPE <br /> XMOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED 132. LEADED ❑ 5. JETFUEL <br /> marked,complete Petroleum Type) 1b. PREMIUM UNLEADED ❑ 3. DIESEL ❑ B. AVIATIONFUEL <br /> ❑ 2. NONFUEL PETROLEUM %1 MIDGRADE UNLEADED ❑ 4. GASOHOL 13 99. OTHER <br /> ❑ 3. CHEMICALPRODUCT <br /> ❑ 4. HAZARDOUS WASTE(Includes COMMON NAME(from HanamouS Matenals Inventaypage) CAS#(from Heandous Materials Inventory papa) <br /> Used 011) Gasoline 800661.9 <br /> ❑95. UNKNOWN <br /> III.TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLEWALLWITH ❑ 5. SINGLE WALL WITH IMERNAL BLADOER SYSTEM <br /> (Check one item qtly) / Xg DOUBLE WALL EXTERIOR MEMBRANE LINER ❑95. UNKNOWN <br /> L/ Cl 4. SINGLE WALL IN A VAULT ❑99 OTHER <br /> TANK MATERIAL-primary bm1 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ 5. CONCRETE ❑95. UNKNOWN <br /> (Check one item only) 2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W1100%METHANOL ❑99. OTHER <br /> REINFORCED PLASTIC FRP <br /> TANK MATERIAL-secOntlary lank ❑ 1 BARE STEEL ❑ 3. FIBERGLASS/PLASTIC '❑� 8. FRPOOMPATIBLEWI100%METHANOL ❑95. UNKNOWN <br /> (Check onettem ally) ❑ 2. STAINLESSSTEEL ❑ 4. STEEL CLAD W/FIBERGLASS(�/-(X p. FRP NON-CORRODIBLE JACKET ❑99. OTHER <br /> REINFORCED PLASTIC(FRP) LJ 10. COATED STEEL <br /> ❑ 5. CONCRETE <br /> TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXYLINING ❑ S. GLASS LINING ❑95. UNKNOWN433 DATE INSTALLED <br /> OR COATING <br /> ❑ 2. ALKYD LINING ❑ 4. PHENOLIC LINING ❑ 6. UNLINED W. OTHER <br /> Check erre Item onlyd IlRolocaluse <br /> OTHER CORROSION ❑ 1. MANUFACTURED CATHODIC El 3, FIBERGLASS REINFORCED PLASTIC ❑95. UNKNOWN 434 DATE INSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION <br /> ❑ 4. IMPRESSED CURRENT El 99. OTHER <br /> (Check one tlem only) ❑ 2. SACRIFIGAL ANODE (Far bPill use or#y) <br /> SPILL AND OVERFILL YEAR INSTALLED TYPE(Forbcal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED <br /> (Check all Mat appy) SPILLCONTAINMENT 2001 / <br /> . ALARM 2001_ 3. FILL TUBE SHUT OFF VALVE <br /> 2. DROPTUBE 2001 <br /> 2, BALL BOAT 2001_ ❑ 4. EXEMPT <br /> LX) STRIKER PLATE 2001 <br /> IV. TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all that apply): IF OOUBLE WALL TANK OR TANK WITH BLADDER(Check one Item only): <br /> ❑ 1, VISUAL(E)UPOSED PORTION ONLY) ❑ 5. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑ 2. AUTOMATICTANK GAUGING(ATG) ❑ 6. VADOSEZONE CONTINUOUS INTERSTITIAL MONITORING <br /> ❑ 3. CONTINUOUSATG ❑ 7. GROUNDWATER ❑ 3. MANUALMONITORING <br /> ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR)+ ❑ e. TANK TESTING <br /> BIENNIAL TANK TESTING ❑99. OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(VRIMOIDAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TAM(FILLED WITH INERT MATERIAL? <br /> oallons ❑Yea ❑No <br /> CUPAFORM(4/99) Formerly SWRCB Form B <br />