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W low UNjdIED PROGRAM CONSOLIDATED FORIr. TANKS \ UNDERGROUND STORAGE TANKS - TANK PAGE I 1 (Two Page. er tank) I lt1by t) Page_of TYPE OF ACTION ® 1.NEW PERMIT ❑ 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) ❑ R TANK REMOVED I. BUSINESS NAME(Same as FACILITY NAME or DBA-Doing easiness As) J. 1 FACILITY ID: Safeway Store#2600- 1987 West 11th Street 431 LOCATION WITHIN SITE(Optional) NE corner of West I Itll Street and Corral Hollow Road L TANK DESCRIPTION (A scaled Plot Plan with the location of the US'f system including buildings and 33landmarks-shall ) ARTMENTALIZED TANK ®Yes ❑ No 43a. TANK ID# 412 TANK MANUFACTURER Modern Welding CO. Inc. IC"Yes;'complete one page for each compartment. x 13 DATE INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 2 2002,March 438. ADDITIONAL DESCRIPTION(For local use only) 11. TANK CONTENTS 440, TANK USE 439. PETROLEUM TYPE ® 1 MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchecked,complete Petroleum Type) ggjab. PREMIUM UNLEADED ❑3. DIESEL 06. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ®Ic. MIDGRADL•UNLEADED [14. GASOHOL ❑99.OTHER: 44z ❑ 441. CAS I/(from Hazardous Materials inventory page) 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) ❑ 4. HAZARDOUS WASTE PREMIUM UNLEADED 8006-61-9 (includes Used Oil) MIDGRADE UNLEADED ❑ 95 UNKNOWN 111. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. MEMBRANE LINER [195. UNKNOWN (Check one item only) 99. OTHER 19 2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT ❑ 4.14 M TANK ATERIAL-primary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE ❑95.UNKNOWN (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑S. FRP COMPATIBLE ❑99.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 8. FRP COMPTIBLE W/100%METHANOL 95,UNKNOWN 445. (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑9. FRP NON-CORRODABLE JACKET [199.OTHER REINFORCED PLASTIC(FRP) ❑10. COATED STEEL ❑5. CONCRETE TANK INTEKIOR LINING 1.RUBBER LINED 3.EPDXY LINING ❑5.GLASS LINING 95.UNKNOWN 446. DATE INSTALLED 447. OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED ❑99.OTHER Chcck one item onl 448. DATE INSTALLED 449. OTHER CORROSION ❑1.MANUFACTURED CATHODIC ®3.FIBERGLASS REINFORCED PLASTIC ❑95.UNKNOWN PROTECTION PROTECTION [14,IMPRESSED CURRENT ❑99.OTHER IfA licablc ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFB.L PROTECTION EQUIPMENT: YEAR INSTALLED 452. ® Phil-Tite85000 ®1.ALARM _ ❑3.FILL TUBE SHUT OFF VALVE (Check all that apply) 1.SPILL CONTAINMENT _2001_ ®2.DROP TUBE _2001 OPW 61T-7368 ®2.BALL FLOAT_ ❑4.EXEMPT ®3.STRIKER PLATE Tank Mfg Modem Welding IV. TANK LEAK DETECTION I (A description of the monitoring program steal l be submitted to the local.igcncy.) 453. IP DOUBLE WALL TANK OR TANK WITH BLADDER 45a. IF SINGLE WALL TANK (Check one item only) (Check all that apply) (31. VISUAL(EXPOSED PORTION ONLY) ❑5.MANUAL TANK GAUGING(MTG) ❑1.VISUAL(SINGLE WALL IN VAULT ONLY [12. AUTOMATIC TANK GAUGING(ATG) El 6.VADOSE ZONE ®2.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG E17.GROUNDWATER [13.MANUAL MONITORING ❑4. STATISTICAL INVENTORY RECONCILIATION ❑8.TANK TESTING (SIR)+BIENNIAL TANK TESTING ❑99. OTHER V;TANK CLOSURE INFORMATION/ PERMANENT CLOSURE IN PLACE' ESTIMATED DATE LAST USED(YR)MO/DAY) 455. ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456. TANK FILLED WITH INERT MATERIAL. 457. gallons ❑Yes ❑ No 10 bl UPCF hwfwrc-b(1/99)-1/4 http://www.unidocs.org//www.unidocs.org Rev.02/16/00