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• UNIFIED PROGRAM CONSOLIDATED FORM l TANK: TA0144602 <br /> j PR#: PR0231446 <br /> UNDERGROUND STORAGE TANKS - TANK P � FAC#: FA0000853 <br /> 17 (two pages per tank) <br /> Pagc 2 of <br /> TYPEOFACTION ❑ 1NEW SITE PERMIT ❑ a+U11]D[U I'I R%11 T ❑ =([f.4li'J 0 F1v1OR%IA110\ ❑ 6 TEMPORARY SITE CLOSURE <br /> (Check Myftanmly) _ "? ❑ 7 PERMANENTLY CLOSED ON SITE <br /> j0 f3 ��-r«Ia lose miry t<P R�' '+�-I�Iaa�emJyl El 8TANK REMOVED 430 <br /> E] 3RENEWAL PERMIT <br /> BUSINESS NAME(samea+FAC1LDYNnMBaDBA-oo4 u�si-A:) FACILITY tD: PR x: <br /> DOCTORS HOSPITAL OF MANTECA FA0000853 PR0231446 <br /> IACATION WUHN SITE(0,6.1) 1205 E NORTH ST,MANTECA 431 <br /> PHONE <br /> t.TANK DESCRIPTION(A scaled plot plan with the lN: --ii :f e UST system including buildings and landts <br /> narks hall be subndtted[o the local agency.) <br /> TANK ID# Tank#: 2 4l2 TANK MANUFACTTIRER 433 COMPARTMENTALIZED TANK E]Yes ❑No 434 <br /> TA0144602 <br /> DATE INSTALLED(YEARMIO) 435 TANK CAPACITY A)GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> 550 <br /> ADDITIONAL DESCRIPTION(Fe local me only) 439 <br /> H.TANK CONTENTS <br /> TANK USE 43q PETROLEUM TYPE "a <br /> ® <br /> I.MOTOR VEMCLE FUEL ❑ 1 a.REGULAR UNLEADED ❑2.LEADED ❑ S.JET FUEL <br /> (ifmhedmnglee Pmokmn Typc) ❑ Ib.PREMIUM UNLEADED ® 3.DIESEL ❑ b.AVIATIONFUEL <br /> ❑ 2.NON-FUEL PETROLEUM ❑ 1 c.MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER <br /> ❑3.CHEMICAL PRODUCT COMMON NAME(6om Haavdm¢Matariala lnv=torypaac) 441 CAS4(6 Hanedeiu Mnenas hcnaay page) 442 <br /> ❑4.HAZARDOUS WASTE <br /> (Mdu UsMon) <br /> ❑95.UNKNOWN <br /> HL TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM M3 <br /> (Clackmeitmonly) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN <br /> ® 2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑ 99.OTHER <br /> TANK MATERIAL-primary tank ❑ I.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 4M <br /> (LTxkmeitenwy) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL <br /> REINFORCED PLASTIC(FRP) ❑ 99.OTHER <br /> TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑ 3.PTBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN M5 <br /> (CTak es ttemmdy) ❑2.STAINLESS STEEL ❑ RETEELC A PLASTIC RRtP cS E] 8.FRP COMPTIBLE W/100%METHANOL <br /> ❑ 10.COATED STEEL ❑ 99.OTHER <br /> ❑ S.CONCRETE <br /> TANK INTERIOR LINING ❑ I.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING E]95.UNKNOWN 446 DATE INSTALLED 447 <br /> OR COATING ❑ M OTHER <br /> fChrk aon i.only) E] 2ALKYDLINING ❑ 4PHENOLIC LINING E] 6UNLINED (Forloaluseonly) <br /> 449 <br /> OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN "a DATEINSTALLED <br /> PROTECTION IF APPLICABLE PROTECTION ❑ 41MPRESSED CURRENT ❑ 99 OTHER <br /> (Clrrkone itamonb) ❑ 2 SACRIFICIAL ANODE (Fon total.only) <br /> SPILL AND OVERFILL YEAR INSTALLL<50 TYPE(loalmceey) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 <br /> (CTut allNv apply) ❑ I SPILL CONTAINMENT ❑ IALARM ❑ 3 FILL TUBE SMUT OFF VALt <br /> ❑ 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT <br /> ❑ 3 STRIKER PLATE FLOAT <br /> IV.TANK LEAK DETECTION(A dea;pti.ordKVXXnw'nppmsmmstwl bcmbervnd totl.e wd.amer.7 <br /> IF SINGLE WALL TANK(Chak all thv apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> (O�kae nenonN) <br /> ❑ 1 VISUAL(EXPOSED PORTION ONLY) E] S MANUAL TANK GAUGING(MTG) ❑ 1 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> E]2AUTOMATIC TANK GAUGING(ATG) ❑ bVADOSE ZONE <br /> ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ S TANK TESTING ❑3 MANUAL MONITORING <br /> (SIR)BIENNIAL TANK TESTING ❑99OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(VR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> U fir.. ❑Yes ❑ No <br /> UPCF(12/99 revised) <br />