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-fa-� � �FIED PROGRAM.CONSOLIDATED NK:ONSOLIDATED FORM TATA05MI2` iI PR#: PRO231069 UNDERGROUND STORAGE TANKS-TANK PAGE 1 FAC#: FA0001909 (two pages per tank) TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑4 AMENDED PERMIT ❑5 CHANGE OF INFORMATIONPage 2 of 5 (Chock only�only) ❑6 TEMPORARY SITE CLOSURE ❑7 PERMANENTLY CL WED ON SITE ❑3 RENEWAL PERMIT ❑STANK REMOVED 430 BUSINESS NAME(same as PAauTY NAME w DeA-Dona Bmmna As) FACILITY ID: PR#: 1 COUNTRY CLUB FOOD&FUEL MINI MART 3 FA0001909 PR0231069 LOCATION WITHIN SITE(optional) 19%W COUNTRY CLUB BLVD,STOCKTON 431 PHONE I.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be suMmtted to the local agency.) TANK ID# Tank#: 4 43z TANK MANUFACTURER 433 COMPARTMENTALIZED TANK TA0508126 �v� ❑Yes [:]No 43a XERXES If"Yes",nroplete one page for cub comma[. DATE INSTALLED(YEAR/MO) a3s TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 4/7/1999 9,000 ADDITIONAL DESCRIPTION(For tont use only) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ® Ia.REGULAR UNLEADED ❑2.LEADED ❑5.JET FUEL (1fmvlmdcompickPmdamType) ❑ lb.PREMIUM UNLEADED ❑3.DIESEL ❑6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ le.MIDGRADE UNLEADED ❑4.GASOHOL ❑ 3.CHEMICAL PRODUCT ❑ •OTHER COMMON NAME(6om Hanrdota Materida lmeatory pap) 441 CAS#(ewn H..d.Mat."i..0 y page) 442 ❑4.HAZARDOUS WASTE (luelodta Used Did ❑95.UNKNOWN M.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check ana its my) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN ® 2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑99.OTHER TANK MATERIAL-primary tank ❑ 1.BARE STEEL ®FIBERGLASS/PLASTIC ❑5.CONCRETE ❑95.UNKNOWN 444 (tel'ane it®may) ❑2.STAINLESS STEEL ❑STEEL CLAD W/FIBERGLASS ❑8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 445 (Chert one item ody) ❑2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑S.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑99.OTHER ❑5.CONCRETE TANK INTERIOR LINING ❑ 447 1.RUBBER LINED OR COATING ❑3.EPDXY LINING ® 5.GLASS LINING E]95.UNKNOWN 446 DATE INSTALLED (Check one item only) ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99.OTHER (For local use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC q49 PROTECTION IF APPLICABLE PROTECTION ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED (Chi me hem my) ❑4 IMPRESSED CURRENT ❑99 OTHER ❑2 SACRIFICIAL ANODE (Far loot use soy) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local we roily) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that appy) ❑ I SPILL CONTAINMENT 1,999.00 El E] 2 DROP TUBE 1?'EARN [-]3 FILL TUBE SHUT OFF VALE ❑ 2 BALL E] 3 STRIKER PLATE E]4 EXEMPT FLOAT IV.TANK LEAK DETECTION(A dee.0.of the mmitormg propam shah be submitted to the low agary) IF SINGLE WALL TANK(Chock a6 that appy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) (Chedc ane item owY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ STANK TESTING (SIR)BIENNIAL TANK TESTING ❑99 OTHER 3 MANUAL MONITORING ❑ V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑No UPCF(12/99 revised)