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r AMD PROGRAM CONSOLIDATED FOS TANKS Ws� S& O 17 UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page_of TYPE OF ACTION ® 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID: 1 Safeway Store#2600-1987 West 11th Street O O LOCATION WITHIN SITE(optional) 431. NE corner of West 11th Street and Corral Hollow Road _........_..... L TANK DESCRIPTION (A sealed plot plan with the location of the UST system including buildings and landmarks shall be submitted to the.local:agency.) TA.N�K 11)4 432. ETANKANUFACTURER 433. COMPARTMENTALIZED TANK ®Yes ❑ No 434. CWeldin Co. Inc. If"Yes,"complete one page for each compartment. DATEINSTALLED 435• APACITY IN GALLONS 436NUMBER OF COMPARTMENTS(YEAR/MO) 43z2002,March 1 ON c1-o-o 2 ADDITIONAL DESCRIPTION(For local use only) 438. II. TANK CONTENTS ..... TANK USE 439. PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ❑1 a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If checked,complete Petroleum Type) ®Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM -90. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441. CAS#(from Hazardous Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE PREMIUM UNLEADED 8006-61-9 (Includes Used Oil) MIDGRADE UNLEADED ❑ 95.UNKNOWN III. TANK CONSTRUCTION' .... TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443, (Check one item only) MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank 0 1. BARE STEEL ❑3. FIBERGLASS/PLASTIC U 5. CONCRETE 0 95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL ®3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL LJ 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED 0 3.EPDXY LINING 0 5.GLASS LINING ❑95.UNKNOWN 446. DATE INSTALLED 447. OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED El 99.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.BAPRESSED CURRENT ❑99.OTHER IfA licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) 19 1.SPILL CONTAINMENT _2001 Phil-Tite85000 ®1.ALARM ❑3.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE _2001_ OPW 61T-7368 ®2.BALL FLOAT ❑4.EXEMPT ®3.STRIKER PLATE Tank Mfg Modem Welding IV. TANK LEAK DETECTION (A description of the monitoring program shalt bo submitted to the local agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 4s.t (Check all that apply) (Check one item 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 [17.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (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. gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00