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'Wh <br /> ified Program Consolidated Fo �ip�a9ld.2- <br /> :TANKSUNDERGROUND STORAGE TANKS -TANKPAGE1 <br /> (one pag .) <br /> Page_of_ <br /> TYPE OF ACTION E]1.NEW SITE PERMIT 114.AMENDED PERMIT 1:15.CHANGE OF INFORMATION 116.TEMPORARY SITE CLOSURE <br /> /CHI/WF ITFM ONI VI <br /> 1:17. PERMANENTLY CLOSED ON SITE <br /> X❑3.RENEWAL PERMIT E-18.TANK REMOVED <br /> (Specify mason-for local use only) (Specify reason-for local use only) 430 <br /> BUSINESS NAME(Sam as FACILITY NAME or DBA-Doing Business As) 3 FACILITYID# . <br /> Jackpot Food Mart, Manteca <br /> LOCATION WITH SITE(Optional) i 431 <br /> � y� 4 W V�semi-l`e <br /> I.TANK DESCRIPTION <br /> TANK ID# L� / 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes DNo 434 <br /> 7 Modern Welding If"Yes"complete one page for each compartment <br /> DATE INSTALLED(YEARIMO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> 9/91 10000 <br /> ADDITIONAL DESCRIPTION(For Ionil use only) 438 <br /> r II. TANK CONTENTS <br /> TANK USE 439 PETROLEUM TYPE 440 <br /> ® 1. MOTOR VEHICLE FUEL Dia. REGULARUNLEADED [:]2. LEADED []5. JET FUEL <br /> (If marked,complete Petroleum Type) <br /> 2. NON-FUEL PETROLEUM [:11b.PREMIUM UNLEADED 1:13. DIESEL [:]6. AVIATION FUEL <br /> 3.CHEMICAL PRODUCT ®1c.MIDGRADE UNLEADED C]4. GASOHOL 099. OTHER <br /> 4. HALARUUUS WAS I e Lncudes Hazardous Materaig inventory page (from Hazardous Materials Inventory page <br /> Used uH) <br /> 095. UNKNOWN <br /> 111. TANK CONSTRUCTION <br /> TYPE OF TANK Ell. SINGLE WALL F]3. SINGLE WALL WITH E]S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> pT EXTERIOR MEMBRANE LINER EXTERIOR MEMBRANE LINER <br /> (Check on Rem only) E32. DOUBLE WALL [:]4. SINGLE WALL IN A VAULT [:16. UNKNOWN <br /> [399.OTHER <br /> TANK MATERIAL-primary tank C]1.BARE STEEL 133.FIBERGLASSIPLASTIC [:]5.CONCRETE [:]95. UNKNOWN 444 <br /> EXTERIOR MEMBRANE LINER <br /> (Check on Hem only) [:]2. STAINLESS STEEL ®4. STEEL CLAD [:]8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER <br /> W/FIBERGLASS <br /> REINFORCED PLASTIC(FRP) <br /> TANK MATERIAL-secondary tank ®1.BARE STEEL ❑3.FIBERGLASS/PLASTIC E]8. FRP COMPATIBLE W/100%METHANOL [-]95. UNKNOWN 445 <br /> (Check on Hem only) [:12. STAINLESS STEEL [:34. STEEL CLAD W/FIBERGLASS []9.FRP NON-CORROSIVE JACKET [:]99.OTHER <br /> REINFORCED PLASTIC(FRP) <br /> [:]b. WNGRt IE C]10. CUAILUSILLL <br /> TANK INTERIOR LINING []1.RUBBER LINED [:]3.EPDXY LINING [:]5.GLASS LINING [:]95.UNKNOWN 446 DATE INSTALLED 447 <br /> OR COATING <br /> [:]2. ALKYD LINING [:]4.PHENOLIC LINING 1:16.UNLINED �99.OTHER <br /> (Check one Rem only) (For local use only) <br /> OTHER CORROSION 448 DATEINSTALLED 449 <br /> PROTECTION IF APPLICABLE(Check �YHMA UFAtCN RED CATHODIC 03.FIBERGLASS REINFORCED PLASTIC [:]95.UNKNOWN <br /> UILUI <br /> (Cheall that apply) 02.SACRIFICIAL ANODE ❑4.IMPRESSED CURRENT [:199.OTHER w focaluse ony <br /> SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(For local use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 <br /> (Check on Hem only) ®1.SPILL CONTAINMENT 1991 451 [:]1.ALARM _ ®3.FILL TUBE SHUT OFF VALVE <br /> ®2.DROP TUBE 1991 [:]2.BALLFLOAT _ [:]4.EXEMPT <br /> [-]3.STRIKER PLATE <br /> IV.TANK LEAK DETECTION <br /> IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one Rem only): <br /> Mi.VISUAL(EXPOSED PORTION ONLY) []5 MANUAL TANK GAUGING(MI E]I VISUAL(SINGLE WALL IN VAULT ONLY)) 454 <br /> ❑2.AUTOMATIC TANK GAUGING(ATG) [-]6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING <br /> [:]3.CONTINUOUS ATG 07.GROUNDWATER ❑3.MANUAL MONITORING <br /> r-14.STATISTICAL INVENTORY RECONCILIATION(SIR)' [:]B.TANK TESTING <br /> 099.OTHER <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YRIMOIDAT) 445 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL' 457 <br /> gallons E]Yes ON. <br /> UPCF(199) Formerly SWRCB Form B <br />