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r UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 1 (Two pages per tank) Page_3._of_ TYPE OF ACTION ® 1.NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430 (Check ane item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ B.TANK REMOVED BUSINESS NAME(Sam..rACl1J7YNAMEor DBA-Doing BusineesAs) 3. FACILITY ID: SafewayInc. l I LOCATION WITHIN SITE(optional) 431- NE comer of West 11th Street and Corral Hollow Road GRIP7�OlN ,, tCK Rl'l 1(It lstiwi' t4xlckiitl0n af, t1ST5yst m fttal cijn �tftldin'sand3gtl�d>t is CE subrai1!,q 'uri4elpF. SIT TANKID k 431 TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ®Yes ❑ No 434, 3, Modern Welding Co.Inc. If"Yes;•cmipltu one page for each camp ent DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS 43' (YEAR/MO) 6 2002 March 10,000 ADDITIONAL DESCRIPTION(Forloeal use only) 43E. TANK USE 439• PETROLEUM TYPE 4 c. ® 1. MOTOR VEHICLE FUEL REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If chocked,complete Petroleum Type) lb. PREMIUM UNLEADED ❑3. DIESEL [16, AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from tb=dous Materials Imentcry page) 441, CAS#(&=Hazardous Maa-rW3Inventury page) 442 ❑ 4. HAZARDOUS WASTE PREMIUM 8006-61-9 (Includes Used Oil) ❑ 95.UNKNOWN �.'x�N`l�G '�I7C mm TYPE OF TANK ❑1. SINGLE WALL 0 3, SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) ME.VBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL ❑4.=ALL IN A VAULT 99. OTHER TANK MATERIAL-primary tusk ®1. BARE STEEL 3. FIBERGLASS i PLASTIC 5. CONCREIx ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL, ❑4. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE ❑99.OTHER REL\TORCED PLASTICRP W1100%METHANOL TANK MATERIAL-Secontlary tank t. BARE STEEL N 3. FIBERGLASS/PLASTIC ❑9.FRP COMPTIBLE Wil 00%METHANOL ❑95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99-OTHER RELNIFORCED PLASTIC(PRP) ❑10. COATED STEEL ❑S.CONCRETE TANTO INTERIOR LINING ❑1.RUBBER LLNM ❑3.EPDXY LLNING 5.GLASS r TNI TG 95.UNKNOWN 446. DATE INSTALLED 44-1 OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED ❑99.OTHER Check one item eml OTHER CORROSION L MANUFACTURED CATHODIC IM 3.FIBERGLASS REINFORCED PLASTIC ❑95,UNKNOWN 44s. DATE INSTALLED 449. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER LA licable 0 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451, 1 OVERFILL PROTECTION EQUIPMENT; YEARINSTALLED 4!2. (Check all that apply) O L SPILL CONTAINMENT _2001_ Phil-Tite85000 N 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 Wel$in AX P -1Pslgllife>rnbunttdd ttkt£e Ycica)a eno5 e IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454. (Check all that apply) (Check one item only) ❑1.VISUAL(EXPOSED PORTION ONLY) ❑S.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2.AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE N 2.CONTINUOUS INTERSTITIAL MONITORING ❑3.CONTINUOUS ATG ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑S.TANK TESTING (SIR)+BDD TIAL TANK TESTING [399.OTHER r...... LtfS ESTIMATED DATE LAST USED(YR/MO/DAY) 455' ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456' TANK FILLED WITH INERT MATERIAL.? 4S. gallons .❑Yes ❑No UPCF hwfwrc-b(1199)-1/4 bttp:/lwww.unldocs org Raw 02/161'00 6 .d 0026 13CN3Sd-1 dH WdOS :b 2002 02 E33