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U11h.a1ED PROGRAM CONSOLIDATED FORIw./ UNDERGROUND STORAGE TANKS - TANK PAGE 1 TANKS TANK #2 Into Pages per tank) TYPE OF ACTION CKI NEW SITE PERMIT ❑ 4 AMENDED PERMITPage_of ❑ S CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check an<iam Doty) � ,/ ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify mnon_for bml uuonly) (specifyreesoo_(m foal use onH) ❑ 8 TANK REMOVED BUSINESS NAME(semees FACBATYNAMEor DBA-Doingnusineo As) FACILITY ID: 430 SAFEWAY FUEL CENTER #1769 3 LOCATION WITHIN SITE(Optione0 431 L TANK DESCRIPTION (A scaled PIM plan with the loe's of[he UST system including buildings and landmarks shag be submitted to the local agerlry.) TANK ID k 43z TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ]Yes ❑ No 434 1769-2 MODERN WELDING BuYet"l000plehcoepegeformchcomp, e,,t DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS \ 43 NUMBER OF COMPARTMENTS 3/1/01 20,000 6f0g0-6 2d?t Q>J 437 ADDITIONAL DESCRIPTION(Por lonlux Doty) 2 433 3- T,¢ t�sisss li.TANK C ENTS TANK USE 439 PETROLEUM TYPE 13' 4. MOTOR VEHICLE FUEL ❑la REGULAR UNLEADED440 ❑2. LEADED ❑5. JET FUEL (Rmarkwoomplerepe°of"mlgTe) ❑lb. PREMIUM UNLEADED 03. DIESEL 06. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER_ ❑3. CHEMICAL PRODUCT COMMON:NAM:E (fieco Ilvardous Meterids Iwenwry peg°) Ml CASH(fiom Hanrdoua Materials Inventory vage) 442 ❑d. HAZARDOUS WASTE (mcludea Used Oil) ❑95.UNKNOWN DL TANK CONSTRUCTION TYPE OF TANK L1 I. SINGLE WALL 3. SINGLE WALL WITH S. SINGLE WALL WITHINTERNAL BLADDERSYSTEM 413 Therkooenem only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN M. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary reek 0 1. BARE STEEL [5 4. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 414 (Check Dee nm on nem [32. STAINLESS STEEL L`74. STEEL CLAD W/FIBERGLASS ❑& FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 0 1. BARE STEEL 0 3. FIBERGLASS/PLASTIC 115. CONCRETE 95. UNKNOWN 445 (Cheticune dim ooly) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/1001A METHANOL [199.OTHER_ REINFORCED PLASTIC(FRP) ❑10.COATED STEEL N/A ❑5. CONCRETE TANK INTERIOR LINING OLRUBBERUNED 0 3.EPDXY LINING M 5.GLASS LINING 0 9S.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑990THER (Check Doe item only) (For loal u1e only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 408 DATE INSTALLED 419 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check one item onty) ❑2 SACRIFICIAL ANODE (Forloceuse poly) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE oorel use only) 451 OVERFILL PROTECTION EQUIPMENTNEAR INSTALLED 452 (Checkell Misapply) ❑ I SPILL CONTAINMENT 200 5 GAL. BUCKET 0 ALARM KI 3 FILL TUBE SHUT OFF VALVE2QQJ.__ ❑2 DROP TUBE 2001 FLOAT VALVE ❑2 BALL FLOAT ❑4 EXEMPT ❑3 STRIKER PLATE -20M 2LATE IV.TANK LEAK DETECTION(A description ofthe monitoring pmgmm shill be wbmakd to the lo®1 agocy.) IF SINGLE WALL TANK(check all Mm oppty) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER ass (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I 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 ❑4STATISTICAL INVENTORY RECONCILIATION ❑STANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No � �