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Allk Ank Inv 1W L,-qA'IED PROGRAM CONSOLIDATED F0k TANKS UNDERGROUND STORAGE TANKS - TANK PAGE I (Two page.,6ptak) Page_of TYPE OF ACTION 1.NEW PERMIT 0 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) ❑ S.TANK REMOVED !;;jj: BUSINESS NAME(Same as FACILITY NAME or DBA-Doing FACILITY Safeway Store#2600- 1987 West 11th Street431. LOCATION WITHIN SITE(optional) NE comer of West 11th Street and Corral Hollow Road I. TANK DESCRIPTION 1. (A scaled plot Plan with the location of the UST s)-stern including buildings and landmarks shall be submitted to the local TANK ID# 432. 1 TANK MANUFACTURER 33 COMPARTMENTALIZED TANK C1 Yes 0 No 434, Modem 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,Much 20,000 0 438. ADDITIONAL DESCRIPTION(For local use only) 11. TANK CONTENTS 440. TANK USE 439- PETROLEUM TYPE 0 1. MOTOR VEHICLE FUEL Ia. REGULAR UNLEADED [12. LEADED El 5. JET FUEL (If checked,complete Petroleum Type) ❑1b. PREMIUM UNLEADED [13. DIESEL El 6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED E14. GASOHOL [199.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441. CAS#(from Hazardous Materials Inventory page) 442. 0 4. HAZARDOUS WASTE REGULAR UNLEADED 8006-61-9 (Includes Used Oil) ❑ 95.UNKNOWN III.TANK CONSTRUCTION 443, EXTERIOR E]�5 TYPE OF TANK [It, SINGLE WALL 0 3 SINGLE WALL WITH I . SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one item only) ME-MBRANE LINER 0 95. UNKNOWN JR 2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT D 99. OTHER 95.UNKNOWN 444. TANK MATERIAL-primary tankDg 1. BARE STEEL U 31. FIBERGLASS//PLASTIC U 5. CONCRETE (Check one item only) 0 2. STAINLESS STEEL [14. STEEL CLAD WIFIBERGLASS ❑8. FRP COMPATIBLE E]99'OTHER:-- REINFORCED PLASTIC TRP) SAT EOL 0 95.UNKNOWN 445, TANKMATERIAL ieccndliii,�tani 1. BARE STEEL 0 3. FIBERGLASS/PLASTIC 8. FRP COWTIBLE W/I 00%METHANOL (Check one item only) El 2. STAINLESS STEEL 114. STEEL CLAD W/FIBERGLASS El 9. FRP NON-CORRODABLE JACKET ❑99.OTHER_ REINFORCED PLASTIC(FRP) 0 10. COATED STEEL 135- CONCRETE 0 5.GLASS LINING [195.UNKNOWN 446. DATE INSTALLED 447. TANK INTERIOR LINING 1.RUBBER D 0 3.EPDXY LINING OR COATING ❑2.ALKYD LINING ❑4.PHENOLIC LINING 0 6.UNLINED 0 99.OTHER (Check one item onI .) - DATE INSTALLED 449. OTHER CORROSION 01.MANUFACTURED CATHODIC 0 3.FIBERGLASS REINFORCED PLASTIC [395.UNKNOWN 448. PROTECTION PROTECTION [14.IMPRESSED CURRENT 0 99.OTHER If Applicable) ❑2.SACRIFICIAL ANODE YEAR INSTALLED 452. SPILL AND OVERFILL YEAR INSTALLED 450 TYPE 451. OVERFILL PROTECTION EQUIPMENT: (Check all that apply) 0 1.SPILL CONTAINMENT 2001_ Phil-Tite85000 N 1.ALARM 0 3.FILL TUBE SHUT OFF VALVE- Z 2.DROP TUBE 2001_ OPW 61T-7368 0 2.BALL FLOAT 114.EXEMPT 23 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 BLADDER (Check all that apply) (Check one item only) E]1.VISUAL(SINGLE WALL IN VAULT ONLY) ❑1. VISUAL(EXPOSED PORTION ONLY) El 5.MAN-UAL TANK GAUGING OITG) 19 2.CONTINUOUS INTERSTITIAL MONITORING ❑2. AUTOMATIC TANK GAUGING(ATG) El 6.VADOSE ZONE 0 3. CONTINUOUS ATO El 7.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION El 8.TANK TESTING f2'D (SIR)+BIENNIAL TANK TESTING 0 99. OTHER V.TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE ::::: : :: : - n:RT RI, 455, ESTIMATED QUANTITY OF 456� TANK FILLED W�ITH [:3 457, ESTIMATED DATE LAST USED(YR/MO/DAY) SUBSTANCE REMAINING 0 YINERT MATERIALI gallons ❑Yes D No UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00