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A. LD PROGRAM CONSOLIDATED FOA TANKS UNDERGROUND STORAGE TANKS - TANK PAGE I (Two pages6ptank) Page_of TYPE OF ACTION 0 1.NEW PERMIT 0 4.AMENDED PERMIT 0 5.CHANGE OF INFORMATION 0 6.TEMPORARY TANK CLOSURE 430. (Check one item only) 0 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: ... ........ ....... ........ ... ........ ........ ........ ..... ....... Safeway Store#2600- 1987 West 11th Street ........ LOCATION WITHIN SITE(Optional) 431 NE comer of West I I th Street and Corral Hollow Road I. TANK DESCRIPTION (A scaled plotplan with the location of the UST.systcm including buildings and landinarks shall be submitted lothe l"AlagQn.cy.) TANK ID# 432 TANK MANUFACTURER 433. COMPARTMENTALIZED TANK E]Yes No 434. 1 Modern Welding Co.Inc. If"Yes,"complete one page for each compartment. DATE INSTALLED 435- TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. (YEAR/MO) 2002,March 20,000 0 ADDITIONAL DESCRIPTION(For local use only) 438. 11. TANK CONTENTS ... .... ............ TANK USE 439. PETROLEUM TYPE 440 19 1. MOTOR VEHICLE FUEL 0 Ia. REGULAR UNLEADED [12. LEADED 0 5. JET FUEL Of checked,complete Petroleum Type) El lb. PREMIUM UNLEADED [13. DIESEL 0 6. AVIATION GAS 0 2. NON-FUEL PETROLEUM C1 lc. IvMGRADE UNLEADED 04. GASOHOL 0 99.OTHER: El 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials inventory pap) 441. CAS#(from Hazardous Materials Inventory page) 442. El 4. HAZARDOUS WASTE REGULAR UNLEADED 8006-61-9 (Includes Used Oil) El 95 UNKNOWN M. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL El 3. SINGLE WALL WITH EXTERIOR 0 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 L1 3. FIBERGLASS/PLASTIC 0 5. CONCRETE LJ 95.UNKNOWN 444. (Check one item only) 0 2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTICgM) W/100%METHANOL TANK MATERIAL-secondary tank El 1. BARE STEEL 0 3. FIBERGLASS/PLAST L1 8. FRP COWT113LE W/I 00%METHANOL LJ 95.UNKNOWN 445. (Check one item only) El 2. STAINLESS STEEL El 4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET 0 99.OTHER_ REINFORCED PLASTIC(FRP) ❑10. COATED STEEL 0 5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED 0 3.EPDXY LINING 0 5.GLASS LINING 0 95.UNKNOWN 446. DATE INSTALLED "T OR COATING 0 2.ALKYD LINING ❑4.PHENOLIC LINING 0 6.UNLINED 0 99.OTHER (Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC 0 95.UNKNOWN 448. DATE INSTALLED 449. PROTECTION PROTECTION El 4.IMPRESSED CURRENT ❑99.OTHER If Applicable) 0 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 45o. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) 0 1.SPILL CONTAINMENT _2001_ Phil-Tite85000 1.ALARM El 3.FILL TUBE SHUT OFF VALVE 2.DROP TUBE 2001 OPW 61T-7368 2.BALL FLOAT El 4.EXEMPT 3.STRIKER PLATE Tank Mfg- Modem Welding IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local.agency.) IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH 131ADDLR 454. (Check all that apply) (Check one item only) El 1. VISUAL(EXPOSED PORTION ONLY) El 5.MANUAL TANK GAUGING(IffG) [11.VISUAL(SINGLE WALL IN VAULT ONLY) [12. AUTOMATIC TANK GAUGING(ATG) 0 6.VADOSE ZONE 2.CONTINUOUS INTERSTITIAL MONITORING El 3. CONTINUOUS ATG 0 7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER Vi:::.TANK CLOSURE INFORMATION''!:PFF-MANENT CLOSURE IN PLACE:::: ................ ........... .......... ESTIMATED DATE LAST USED(YR/MO/DAY) 415. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456, TANK FILLED WITH INERT MATERIAL? 457. gallons 0 Yes 0 No UPCF hwfwre-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00