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p(D I IED PROGRAM CONSOLIDATED FORMU TANK: TA0515636 10 / PRO: PROSI8442 UNDERGROUND STORAGE TANKS -TANK PAGE 1 FAC#: FAD013913 (two pages per tank) TYPE OF ACTIONPagc 2 of3 (CFcck ody imm only) ❑ INEW SITE PERMIT ❑4AMENDED PERMIT SCHANGE OF INFORMATION ❑ 6TEMPORARY SITE CLOSURE ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3RENEWAL PERMIT ❑STANK REMOVED 430 BUSINESS NAME(Sime a FACILITY NAME«DBA-Doing Bmmms As) 3 FACILITY ID: PRN: I HERITAGE SQUARE FA0013913 PR0518442 LOCATION WITHIN SITE(opaa o) 640 N SAN JOAQUIN,STOCKTON 431 PHONE 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# Tank#: 1 43z TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 TA0515636 If sampina me pose ra ma nompa,m int DATE INSTALLED(YEAR/MO) 433 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 500 ADDITIONAL DESCRIPTION(For lord use oJy) 438 D.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑ I.MOTOR VEHICLE FUEL ❑ la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (IfmmUd,mnplgePNplmiType) ❑ Its.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ )c MIDGRADE UNLEADED ❑ 4.GASOHOL ® 99.OTHER ❑3.CHEMICAL PRODUCT COMMON NAMEfrom Ha amous Mmumis Immum, CAS# fmn Hamnkm Mnmdals mm ntan ( paSel 44l ( 'Page) 02 ❑4.HAZARDOUS WASTE (Imludm Uxd Oil) ®95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ® 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Ckak=inmamnk) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ❑ 2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ® I.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Cock aai=aNy) ❑ 2.STAINLESS STEEL E] STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/10070 METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (CM1 k mm ilei only) ❑ 2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ S.FRP COMPTIBLE W/100°.METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ L RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 047 OR COATING (Chk one iam onh) ❑2ALKYD LINING ❑4PHENOLIC LINING ® 6UNLINED ❑ 99.OTHER (Fa I«al useaNy) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN US DATEINSTALLED 009 PROTECTION IF APPLICABLE PROTECTION (Clkmmllcmonl,) ❑ 4 IMPRESSED CURRENT ❑ 99 OMER ❑ 2 SACRIFICIAL ANODE (Farlccelmcanly) SPILL AND OVERFILL YEAR MSTALLE450 TYPE(laol ua anh) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Ch J:as wm appb) ❑ I SPILL CONTAINMENT ❑ )ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT ❑ 3STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A doixmptiouaria uw.itadus pmgam sb.n b aubmind m bal«al.a .-.) IF SINGLE WALL TANK(Cluck all diat apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (C3eckom nem anh) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL M VAULT ONLY) ❑ 3CONTINUOUS ATG ❑ 7GROUNDWATER ❑2 CONTINUOUS INTERSTITIAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SBR)BIENNIAL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/M30/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 8/1/1986 12:00:OOAM 0.00 gallons ❑ Yes ❑No UPCF(12/99 revised)