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UFIED PROGRAM CONSOLIDATED FORK TANK: TA0515608 PR#: PR0517565 UNDERGROUND STORAGE TANKS - TANK PAGE 1 FAC#: FA0013503 (two pages per tank) TYPE OF ACTION Page 6 of 7 (C��items) ❑ 1 NEW SITE PERMIT ❑4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑6 TEMPORARY SITE CLOSURE ❑ 7 PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT (Specify remora-f«local use Only) (Specify reason-for local use only) ❑ ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR»: l SAFEWAY#2600 3 FA0013503 PR0517565 jjFMM LOCATION WITHIN SITE(Optional) 1987 W 11TH ST,TRACY 431 PHONE 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# Tank#: 3 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ®Yes ❑No 434 TA0515608 MODERN WELDING CO INC If"Yes",complete one page for each compartment DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 10,000 ADDITIONAL DESCRIPTION(For local use only) 438 IL TANK CONTENTS TANK USE a,,, PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ❑ la.REGULAR UNLEADED ❑ 2.LEADED ❑5.JET FUEL (If markod complete Petroleum Type) ❑ lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ® I c.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(Gran Hazardous Materials Inrrnlory page) 44l CAS#(from Hazardous Materials Imcntory page) 442 ❑4.HAZARDOUS WASTE (Includes used Oil) 8006-61-9 ❑95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 413 (Check one item only) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN ® 2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ® 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑5.CONCRETE ❑95.UNKNOWN 444 (Check ane item only) ❑2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ®3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 44i (Check one item only) ❑2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ S.FRP COMPTIBLE W/1001%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑5.CONCRETE TANK INTERIOR LINING ❑ 1. ❑ .EPDXY LINING 447 OR COATING RUBBER LINED 3 ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED (Check one item only) ❑2 ALKYD LINING ❑ 4 PHENOLIC LINING ® 6 UNLINED ❑99.OTHER (Fa local use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ® 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 44 PROTECTION IF APPLICABLE PROTECTION (Check onto item only) [j4 IMPRESSED CURRENT ❑ 99 OTHER ❑ 2 SACRIFICIAL ANODE (For leaf use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 1''- (Check all that apply) ® I SPELL CONTAINMENT 2,001.00 PHIL-TITE85000 ® 1 ALARM ❑ 3 FILL TUBE SHUT OFF VALn 0 2 DROP TUBE 2,001.00 OPW61 T-7368 ® 2 BALL ❑4 EXEMPT 0 3 STRIKER PLATE 2,001.00 MODERN WELDIN( FLOAT IV.TANK LEAK DETECTION(A description of the monitoring program shall he suhmitted to the local agmey.) IF SINGLE WALL TANK(Click all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER rl ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item only) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑ 7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V.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 10/16/2001 12:00:OOAM 0.00 gallons ❑Yes ❑No UPCF(12/99 revised)