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wFIED PROGRAM CONSOLIDATED FVV TANKS UNDERGROUND STORAGE TANKS TANK PAGE 1 (two pages per tank) Psgc 3 of6 TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT M 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specifyreazon-forlocaluseonly) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same FACILITY NAME or DBA-Doing Bwinas As) 3 FACILITY ID: 0 00 0 0 0 0 0 0 0 Q Chevron Station#200764 LOCATION WITHIN SITE hoptionao 431 4747 West Lane,Stockton CA 95210 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 0 Yes ® No 434 2 O WENS CORNING IP'Yee",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 035 TANK CAPACITY IN GALLONS a36 NUMBER OF COMPARTMENTS 437 9/28/90 12,000 0 ADDITIONAL DESCRIPTION(Foe local me only) 438 H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 M 1. MOTOR VEHICLE FUEL [Ila. REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL (lfmarked coreglete Peuuleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM M Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER [13. CHEMICAL PRODUCT COMMON NAME (nom Hazardous Materials Inventory pose) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE , (InclwerUseclOil) MID-GRADE UNLEADED 800-61-9 ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER 095. UNKNOWN 02. DOUBLE WALL ❑4. SINGLE WALL IN VAULT [199. OTHER TANK MATERIAL-primarytank ❑1. BARE STEEL M3. FIBERGLASS/PLASTIC [15. CONCRETE 095. UNKNOWN 444 (Check one item only) [12. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑8. ERP COMPATIBLE W/100%METHANOL ❑99.OTHER_ REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑1. BARE STEEL M3. FIBERGLASS/PLASTIC ❑5. CONCRETE 095. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [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 ❑5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING M 6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC M 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN a4g a4g PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Chak one hem only) ❑2 SACRIFICIAL ANODE (Fork�l me only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ® 1 SPILL CONTAINMENT M 3 FILL TUBE SHUT OFF VALVE 1990 M I ALARM OPW 61-SO-4 ®2 DROP TUBE 1998 OPW 61-SO4 ❑2 BALL FLOAT _ ❑4 EXEMPT ®3 STRIKER PLATE Tank Mf _ IV.TANK LEAK DETECTION(A description ofthe monitoring program shall be submitted to the IoW agency) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING INTO) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE M 2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 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 ❑ No UPCF(1/99 revised) 175 Formerly SWRCB Form B