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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (Two pages per tank) Page 2._of- TYPE OF ACTION ® 1.NEW PERMIT ❑ a.AMENDED PERMIT ❑ S.CHANGE OF INFORMATION ❑ 6.TEMPORARY TAONK CLOSURE 430. (Check one Item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMAN>iVIT.Y CLOSED ON SITE (Specify reasaa) (S;.ecify reaso(f) ❑ 8.TANK REMOVED BUSINESS NAME(gene as FACK_ITYNAME or DBA-Doing Basmmt As) 3, FACILITY ID: = t Safeway Inc. !!iE LOCATION WITHIN SITE(Optional) 431. NE comer of West 11th Street and Corral Hollow Road I.T1C ESCRIPTIQN r;> 2;r 7 a,•,. fS 11 With fitz iocatiou of ttic LIST sysAt m irc'4{` buildings,-WQdn } i3kl br submit TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ®Yes ❑ No a3a. 2. Modern Welding Co.Inc. If-Yes,"complee one page for each eamperSment- DATE INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437. (YEAR/MO) xC- 2002 March 10 000 9n - ADDITIONAL DESCRIPTION(For local me 0121y) 438. TANK USE 439. PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL &a, REGULAR UNLEADED ❑2.LEADED ❑5. JET FUEL (Ifcheelced,complete PeoolcumType) ❑I REMIUM UNLEADED [33. DIESEL 136. AVIATION GAS El 2. WON-FUEL PETROLEUM 10.MIDGRADE UNLEADED ❑4.GASOHOL ❑99.CrrHER: El 3. CHEMICAL PRODUCT COMMON NAME(fknin H=rdow btateriak Inventory page) 441. CAS#(from H..dow Materials Inventory pep) a42. ❑ 4. HAZARDOUS WASTE MIDGRADE 9006-61-9 (Indudcs Used Oil) ❑ 9S.U1 KNOWN . A1Nk, QNSTRL(cTYtoN TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH E.\TEMOR ❑5. SINGLE'WALI,WITH NI .AL BLADDER SYSTEM 443 (Check One item only) MEMBRANE LINER ❑95. UN"OWN 2. DOUBLE WALL 4. SINGLE WALL IN A VAULT 99.OTHER TANK MATERIAL-pnnmrytank ®1. HARE STEEL ❑3. FIBERGLASS I PLASTIC 5. CONCRETE 095,UNICNOWN 474. (Check cce item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS ❑S. FRP COMPATIBLE [199.OTHEEL REINFORCEDPLASTTC RP W/100%METHANOL TANK MATERIAL-secondary tank 1.BARE STEEL 3.FIBERGLASS/PLASTIC B. FRP COMPTIBLE W/100•/a METHANOL 95.UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL❑4. STEEL CLAD WRIBERGLASS ❑9. FRP NON-CORRODABLE JACKET ❑99.OTHER IRHINFORCED PLASTIC(FRP) ❑L0. COATED STEEL El S.CONCRETE TANK INTERIOR LINING ❑T.RUBBER LINED 3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 44b. DATE INSTALLED 447. OR COATING 132.ALKYD LLNING ❑4.PHENOLIC LINING ®6.UNLINED ❑99.OTHER Check one item only OTHER CORROSION 1.MANUFACTURED CATHODIC N3.FIBFRGLASSREINFORCEDPLAST1C 095.UNKNOWN 448. DATE-INSTALLED 479. PROTECTION PROTECTION ❑4.IMPRESSED CURRENT ❑99.OTHER Applicable) 2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. 1 TYPE 451. 1 OVERFILL FROTECMON EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ®L.SPTLL CONTAINMENT _2001_ Phil-Tite85000 ®1.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE ®2.DROP TUBE _2001_ OPW 6IT-7368 ®2.BALL FLOAT_❑4.EXEMPT 3.STRRERPLATE Tank Mfg Modem Weldln 1x. TV.TANK UAK DETECUON: A.deseLt o0 0 J(I? .... an shall subtnitJed to the 1daI a en 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) ❑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 ❑7.GROUNDWATER ❑3.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANX TESTING (SUt)+BIENNIAL TANK TESTING ❑99. OTHER 3 shi V TANF CLI S TIONNi P RALANVNT CI�QSI,rRE IN::PLACE ESTIMATED DATELAST USED(1 R 140 DnY) 455 ESTIMATED QUANTITY OF SC HSTA CE RLI AIMING 456' TANK FLLLPD R'I Ji INEK I'NLATERLAL2 457' gallons ❑Yes ❑ No UPCF hw•fwrc-b(1/99)-1/4 bttp://ww-.unidocs.org Rev.01/16100 z .d OOZE 13C21dS1J1 dH WdOS :fr z00Z OZ Hid