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Una,ED PROGRAM CONSOLIDATED FORN.4/ TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages pef tank page�ef TYPE OF ACTION )hI NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE 1(�, ❑ 7 PERMANENTLY CLOSED ON SITE (cnwk ooe henn only) 43a ❑ 3 RENEWAL PERMIT (Specify seasmt-f«Ioaluseonly) (SPaafy'a'en-forhkcaluseoey) ❑ 8 TANKREMOVED BUSINESS NAME(Sameu FACffIT NAME«DB1 bin a Busivees As) FACILITY ID: 1 SAFEWAY FUEL CENTER #1769 3 431 LOCATION WITHIN SITE(optionso L TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted[o the local agency.) TANK[D# a3z TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes No 434 1769-1 05l�557 MODERN WELDING X-Yee",complem one page fec each computment. DATE INSTALLED(YEAR/MO) 415 TANK CAPACITY IN GALLONS 416 NUMBER OF COMPARTMENTS 437 3/1/01 20,,000 ma ADDITIONAL DESCRIPTION(F«krslnee ooly) IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 4/0 Ise L MOTOR VEHICLE FUEL 09 la REGULAR UNLEADED [12 LEADED ❑5. JET FUEL (Rmedeel mplae Peholwm Type) ❑Ib. PREMIUM UNLEADED 03. DIESEL 06. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER [:13. CHEMICAL PRODUCT COMMON NAME (aom Haeudous Materials lnn wq page) 441 CAS#(ft.tiwkdoue Mmekials lnvemary page) 442 ❑4. HAZARDOUS WASTE nadides Wed OS) ❑95.UNKNOWN IIL TANK CONSTRUCTION TYPE OF TANK LSINGLEWALL 3. SINGLE WALL WITH 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one'mm only) EXTERIOR MEMBRANE LINER 095. UNKNOWN [N. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-pdmmy ank ftil. BARESTEEL 0 3. FIBERGLASS/PLASTIC 0 S. CONCRETE LJ 95. UNKNOWN 444 (Checkonenancnly) 02. STAINLESS STEEL 04. STEEL CLAD W/FIBERGLASS 08. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER_ REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE 95. UNKNOWN 445 (Cheek one itm.1,) ❑2. STAINLESS STEEL [A 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W1100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑S. CONCRETE TANK INTERIOR LINING OLRUBBERLINED U 3.EPDXY LINING }}�� 5.GLASS LINING 95.UNKNOWN Me DATE INSTALLED 4 7 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING R3 6 UNLINED ❑99 OTHER (Chakone nem on y) (Fccloal ae anly) OTHER CORROSION ❑I MANUFACTURED CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Checkcnenemaoy) N/A ❑2 SACRIFICIAL ANODE (F«loal use only) SPILL AND OVERFILL YEARINSTALLED 4% TypE(Wdua<mky) 451 OVERFILL PROTECTION EQUIPMENT-YEAR INSTALLED 452 (Check ill ma appy) ❑1 SPILL CONTAINMENT 2001 5 GAL. BUCKET ❑ I ALARM XLy 3 FILL TUBE SHUT OFF VALVE 2001 ❑2 DROP TUBE 2001 FLOAT VALVE ❑2 BALL FLOAT ❑4 EXEMPT ❑3 STRIKER PLATE 2001 PLATE IV.TANK LEAK DETECTION(A description ofthe monitoring pmg %hall be wbmlaed to the loaf agmry) IF SINGLE WALL TANK(check a8 that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Cheek one horn only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) y❑y�1 VISUAL(SINGLE WALL IN VAULT ONLY) L7 ❑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 /❑Y�ess [I No `r �/�/