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UNIFIED PROGRAM CONSOLIDATED FORM !(twwo 1pUNDERGROUND STORAGE TANKS TANK PAGE 1 TANKSpages per tank) TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMITPage I of 6 ® 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 3 RENEWAL PERMIT ❑ T PERMANENTLY CLOSED ON SITE (Spedfyreaaon flout use only) (Specify rumen-for bat use only) ❑ 8 TANK REMOVED BUSINESS NAME(Same u FACILITY NAME.,DBA- d30 fling Business As) 3 FACILITY ID: 0 0 0 O O Chevron Station#200764 0 0 0 0 0 0 I LOCATION WITHIN SITE(o,m m, 4747 West Lane, Stockton CA 95210 431 I.TANK DESCRIPTION (A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted[o the local agency.) TANK ID#,,ff �j 432 TANK MANUFACTURER 4v 3 Tit a44 COMPARTMENTALIZED TANK ❑Yes ® No 434 Y OWENS CORNING 1f"Yei',compine one page for each mmpanmanl. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 9/28/90NUMBER OF COMPARTMENTS 12,000 I417 ADDITIONAL DESCRIPTION(For local use only) 0 438 11.TANK CONTENTS TANK USE 439 PETROLEUM TYPE ®1. MOTOR VEHICLE FUEL N la. REGULAR UNLEADED 440 (Ifmmkd compine Petroleum Type) ❑2. LEADED ❑L JET FUEL ❑1 It. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑10 MIDGRADE UNLEADED ❑q GASOHOL ❑99.OTHER_ ❑3. CHEMICAL PRODUCT COMMON NAME (6om Haaardou MaterOB Inwram ❑4. HAZARDOUS WASTE rYp°ge) 041 CAS#(fromHmNous Materials lnvemory page) 442 B«bd.Used Oil) REGULAR UNLEADED ❑95.UNKNOWN 800-61-9 TYPE OF TANK 111. TANK CONSTRUCTION ❑1. SINGLE WALL ❑3. SINGLE WALL BRA ❑5. SINGLE WALL WITH INTERNAL (Check one hem only) EXTERIOR MEMBRANE LINER 095. UNKNOWN BLADDER SYSTEM 443 ®2. DOUBLE WALL ❑4. SINGLE WALL M VAULT 1199 OTHER_ TANK MATERIAL-primuy unk ❑I. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑5. CONCRETE 1195. UNKNOWN Odd (Chad one hmatmly) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑B. FRP COMPATIBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) -- TANK MATERIAL-secondary tank ❑ I. BARE STEEL ®3. FlBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W1100%METHANOL 11" OTHER REINFORCED PLASTIC(FRP) [110.COATED STEEL -- ❑5. CONCRETE TANK INTERIOR LININGHPROTECTJON LINED ❑3.EPDXY LMMG ❑5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING NING ❑4 PHENOLIC LINING W 6 UNLINED (Checkeim ham only) ❑99OTHER (For local use only) OTHER CORROSION URED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC4e Cl❑95 UNKNOWN 448 PROTECTION IF APPLICAN ❑4 IMPRESSED CURRENT(Check one hem only) L ANODE ❑99 OTHER SPILL AND OVERFILL YEAR INSTALLED 450 (For local use only) TYPE(butuuonly) 451 (Check all that apply) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 ®1 SPILL CONTAINMENT 1990 ®3 FILL TUBE SHUTOFF VALVE ®2 DROP TUBE ® I ALARM OPV+'6I-SO4 1998 OP W 61-SO-4 __❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE Tank Mf1. IV.TANK LEAK DETECTION(A description ofthe menhoring program shall be a bmklw to she bol agency.) IF SINGLE WALL TANK(Check an mel apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 4M ❑I VISUAL(EXPOSED PORTION ONLY) 115 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL M VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 10 2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG 117 GROUNDWATER ❑4 STATISTICAL INV[NTORY RECONCILIATION ❑3 MANUAL MONITORING ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER _ IV.TANK CLOSURE INFORMATION/PERMANENT LOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING - 456 TANK FILLED WITH INERT MATERIAL? 453 gallons ❑Yes ❑ No I IPCF(1/99 revised) 173