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FIED PROGRAM CONSOLIDATED FOR TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page-of TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ® 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANKREMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Ooing Business As) 3 FACILITY ID: F A 0 1 0 1 0 2 4 7 9 1 1 7-Eleven#17334 LOCATION WITHIN SITE(Optional) 431 4501 Pershing Ave. Stockton, CA 1.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 2 Total Containment If'Yes,complete one page for each compo anent. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 638 1 NUMBER OF COMPARTMENTS 437 4/1998 10,000 ADDITIONAL DESCRIPTION(F«local use only) 438 II.TANK CONTENTS TANK USE 438 PETROLEUM TYPE 440 10 1, MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (If marked compete Petroleum Type) 011b. PREMIUM UNLEADED [13. DIESEL [16. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE Gasoline (Includes Used Oil) [195 UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL 1-13.SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER 095. UNKNOWN ®2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER_ TANK MATERIAL-primary tank ®1. BARE STEEL [13. FIBERGLASS/PLASTIC [15. CONCRETE [195. UNKNOWN 444 (Check we item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE W/ ❑99.OTHER REINFORCED PLASTIC(FRP) 100%METHANOL TANK MATERIAL-sewndantank ❑1. BARE STEEL [13. FIBERGLASS/PLASTIC ❑5. CONCRETE [195. UNKNOWN 445 (Check one item only) [12. STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ®99.OTHER REINFORCED PLASTIC(FRP) W1100%METHANOL [15. CONCRETE [110,COATED STEEL TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING [195.UNKNOWN 406 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ®1 MANUFACTURED CATHODIC❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:VEAR INSTALLED 452 (Check all ®1 SPILL CONTAINMENT that apply) 2003 ❑1 ALARM ®3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2003 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 1998 IV.TANK LEAK MfiTION(A description of the monitonng program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 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 ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING +(SIR) BIENNIAL TANK TESTING 0 9 OTHER IV.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAV) 455 ESTIMATED QUANTITY OF SUBSTANCE 456 TANK FILLED WITH INERT MATERIAL? 457 REMAINING gallons El Yes ❑ No UPCF(1/99 revised) Formerly SWRCB Form B