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IED PROGRAM CONSOLIDATED FORM TANK: TA0507994 PR#: PR0231233 UNDERGROUND STORAGE TANKS - TANK PAGE 1 FAC#: FA0002479 (two pages per tank) TYPE OF ACDON ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE Page 4 of5 (check only nen only) jl�',(Sp4vty n for ❑ 7PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT ❑8 TANK REMOVED O I a3o BUSINESS NAME(Samcat FACRITY NAME or DBA-Doing Buaine:a.) 1ACI II IY ID: PR;t: 1 1 7 ELEVEN#17334 D/2237 ' FA0002479 PR0231233 LOCATION WITHIN SITE(opriona0 4501 N PERSHING AVE,STOCKTON 431 PHONE u I.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted m the local agency.) y�,,,� TANKID# Tank#: 5 412 TANK MANUFACTURER 411 COMPARTMENTALIZED TANK []Yes ❑No 434 111) TA0507994 TOTAL CONTAINMENT Ir'Y.-'oaotIcteme WgerarnchmnParm�mt. J DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 416 NUMBER OF COMPARTMENTS 437 hh�� 4/3/1998 10,000 1,kJ ADDITIONAL DESCRI?TION(Fortocaluaeany) 438 ll.TANK CONTENTS �(l� TANK USE 419 PETROLEUM TYPE 440 ® I.MOTOR VEHICLE FUEL ® la.REGULAR UNLEADED ❑ 2.LEADED ❑ S.JET FUEL 0fmartd mnQm<PeaalemnType) ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ to.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME amn Haadaaa moomia i.voa CAS# amnnnn mMat hblmml ( mYPaBe) 441 ( °n'Page) 442 ❑ 4.HAZARDOUS WASTE (Ircludea Used Dib ❑ 95.lINKNOWN HI.TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Click one hent o*) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ® 2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ® 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 444 (Click one nem only) ❑2.STAINLESS STEEL ❑ STEELCLADW/FIBERGLASS ❑ 8.FKP COMPTIBLE W/IO0�sMETRANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ I.HARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN MS (Check one item only) ❑ 2.STAINLESS STEEL ❑ 4.STEEL CLADW/FIBERGLASS ❑ 8.FRPCOMPTIBLEW/I XMETHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL 99.OTHER ❑ 5.CONCRETE yxoc TANK INTERIOR LINING ❑ 1,RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED aa7 OR COATING (Cheskone itemaNy) ❑ 2 ALKYD LINING ❑4 PHENOLIC LINING ® 6 UNLINED ❑ 99.OTHER (Par laol use mdy) OTHER CORROSION ® 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED u9 PROTECTION IF APPLICABLE PROTECTION (06ck ons ona any) ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER ❑ 2SACRIFICIAL ANODE (Fmloul ucanly) SPILL AND OVERFIL YEARINSTALLE450 TYPE(locaiweonly) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 I SPILL CONTAINMENT 1,998.00 y (Click all Watappy) �1 ALARM 1 ❑3 FILL TUBE SHUT OFF NAL` 2DROPTUBE % 2BALLE] 4EXEMPT 3STRIKERPLATE FLOAT IV.TANK LEAK DETECTION(A downpdon ofua monnarto,pmgam stall be sobmfncdm rhe 1=1 gene,) IF SINGLE WALL TANK(Checkall tla,a ty) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (C one imn only) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑ 7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING (SIR)BIENNIAL TANK TESTING F1 99 3 MANUAL MONITORING 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 JEMMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑No UPCF(12/99 revised)