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IFIED PROGRAM CONSOLIDATED F TANKS UNDERGROUND STORAGE TANKS TANK PAGE 1 (two pages per tank) Page 1 of 6 TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ® 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check.dem only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Spocifyreason-forlocalaseonly) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID: O O O O O 0 0 0 0 0 0 Chevron Station#200764 LOCATION WITHIN SITE(optional) 431 4747 West Lane, Stockton CA 95210 I.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 1 OWENS CORNING If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY M GALLONS 436 NUMBER OF COMPARTMENTS 437 9/28/90 12,000 0 ADDITIONAL DESCRIPTION(For local we only) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®I. MOTOR VEHICLE FUEL ®Ia. REGULAR UNLEADED ❑2. LEADED [IS. JET FUEL (Ifmarked complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER [13. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory pose) 441 CAS#(from He amicus Materials inventory page) 442 ❑4. HAZARDOUS WASTE pncmd.Used on) REGULAR UNLEADED 800-61-9 ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑3. SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 02. DOUBLE WALL ❑4. SINGLE WALL IN VAULT [199. OTHER_ TANK MATERIAL-primary tank ❑1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER _ REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary look 01. BARE STEEL ®3. FIBERGLASS/PLASTIC 05. CONCRETE 095. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FTHERGLASS [18. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER_ REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one hem only) (For IoW use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC 19 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 448 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (Forlecalmemly) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ®1 SPILL CONTAINMENT ®3 FILL TUBE SHUT OFF VALVE 1990 ®1 ALARM OPW 61-SO-4 ®2 DROP TUBE 1998 OP W 61-SO-4 ❑2 BALL FLOAT _ ❑4 EXEMPT ®3 STRIKER PLATE Tank Mf IV.TANK LEAK DETECTION(A description ofthe monitoring 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 dem 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 [:199 OTHER _ IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes E] No UPCF(1/99 revised) 173 Formerly SWRCB Form