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Ask Ask low U.-aFIED PROGRAM CONSOLIDATED F01kvA TANKS UNDERGROUND STORAGE TANKS - TANK PAGE I (Two pages per tank) Page_of TYPE OF ACTION 0 1.NEW PERMIT ❑ 4.AMENDED PERMIT El 5.CHANGE OF INFORMATION 0 6.TEMPORARY TANK CLOSURE 430. (Check one item only) 0 3.RENEWAL PERMIT El 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify reason) ❑ 8.TANK REMOVED BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. 1 FAC ILITY ID: 1 Safeway Store#2600- 1987 West 11th Street LOCATION WITHIN SITE(optional) 431, NE comer of West 11th Street and Corral Hollow Road I. TANK DESCRIPTION :(Aacaled plot plan Nvith the location ofthe UST system including buildings and landmarks shall be submitted to the local agency,) TANK ID# 432. TANK MANUFACTURER 433. COMPARTMENTALIZED TANK Z Yes Lj No 434. �)K d. 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) 2 2002,March 0I a-a--o -- 438. ADDITIONAL DESCRIPTION(For local use only) 11. TANK CONTENTS -TANK USE 439- PETROLEUM TYPE 440 0 1. MOTOR VEHICLE FUEL ❑Ia. REGULAR UNLEADED 02. LEADED [15. JET FUEL ofthecked,complete Petroleum Type) lb. PREMIUM UNLEADED 0 3. DIESEL El 6. AVIATION GAS 0 2. NON-FUEL PETROLEUM -Ra. M[DGRADE UNLEADED 0 4. GASOHOL D 99.OTHER: [1 3. CHEMICAL PRODUCTCOMMON NAME (from Hazardous Materials Inventory page) 441. CAS#(from Hazardous Materials inventory page) 442, 0 4. HAZARDOUS WASTE PREM UNLEADED 8006-61-9 (includes Used Oil) MIDGRADE UNLEADED 0 95.UNKNOWN M. TANK CONSTRUCTION TYPE OFTANK [11..1 SI I NGI WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANE LINER ❑95. UNKNOWN 0 2. DOUBLE WALL [14. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank 101. BARE STEEL 0 3. FIBERGLASS/PLASTIC Li 3. CONCRETE 95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL D 4. STEEL CLAD W/FIBERGLASS El 8. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC(FRP) W/100%IvMTHANOL TANK MATERIAL-secondary tank U 1. BARE STEEL 0 3. FIBERGLASS/PLASTIC El 8. FRP COMPTIBLE W/I 00%METHANOL D 95.UNKNOWN 445.. (Check one item only) 0 2. STAINLESS STEEL 0 4, STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET El 99.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL 0 5. CONCRETE 0 95.UNKNOWN 446. DATE INSTALLED 447. TANK INTERIOR LINING 1.RUBBER LINED 0 3.EPDXY LINING 5.GLASS LINING 99.OTHER OR COATING C32.ALKYD LINING [14.PHENOLIC LINING 6.UNLINED ❑ (Check one item onlv)- 0 95.UNKNOWN 448. DATE INSTALLED 449. OTHER CORROSION 0 1 MANUFACTURED CATHODIC D9 3.FIBERGLASS REINFORCED PLASTIC PROTECTION PROTECTION 0 4.IMPRESSED CURRENT ❑99.OTHER - (IfApp icable) ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) 10 1.SPILL CONTAINMENT 2001_ Phil-Titi:85000 0 1.ALARM D 3.FELL TUBE SHUT OFF VALVE - 2.DROP TUBE -2001_ OPW 61T-7368 0 2.BALL FLOAT 4.EXEMPT 3.STRIKER PLATE Tank Mfg Modem Welding ............. IV. TANK LEAK DETECTION (A description of the monitoringprogram shall be submitted to the local.agency.) - IF SINGLE WALL TANK 453. IF DOUBLE WALL TANK OR TANK WITH BLADDER 454� (Check all that apply) (Check one item only) [11. VISUAL(EXPOSED PORTION ONLY) El 5.MANUAL TANK GAUGING(mrG) 0 1.VISUAL(SINGLE WALL IN VAULT ONLY) El 2. AUTOMATIC TANK GAUGING(ATG) El 6.VADOSE ZONE N 2.CONTINUOUS INTERSTITIAL MONITORING [13. CONTINUOUS ATG E]7.GROUNDWATER 0 3.MANUAL MONITORING El 4. STATISTICAL INVENTORY RECONCILIATION 0 8.TANK TESTING (SIR)+BIENNIAL TANK TESTING 0 99. OTHER V. TANK CLOSURE INFORMATION PERMANENT CLOSURE IN PLACE 6 ESTIMATED DATE LAST USED(YR/MO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. T ANK FILLED WITH INERT MATERIAL? 457. gallons [3 Yes [I No &) IDII-,51-o/ UPCF hwfivrc-b(1/99)-1/4 http://www.unidocs.org Rev.02/16/00