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� 1FIED PROGRAM CONSOLIDATED FORM TANK: TAOM127 �/ PR#: PPM3100 UNDERGROUND STORAGE TANKS -TANK PAGE 1 FAC#: FA000190 (two pages per tank) TYPE OF ACTION ❑ I NEW SITE PERMIT ❑4 AMENDED PERMITPage 4 of 5 ❑5 CHANGE OF INFORMATION []6 TEMPORARY SITE CLOSURE ❑7 PERMANENTLY CLOSED ON SITE ❑3 RENEWAL PERMIT ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACarrY NAw or DBA-Doing Bu.mess As) FACILITY ID: PR#: 1 COUNTRY CLUB FOOD&FUEL MINI MART i3 FA0001909 PRO 31069 LOCATION WITHIN SITE(option.0 18%W COUNTRY CLUB BLVD,STOCKTON 431 PHONE I.TANK DESCRIPTION(A scaled plot pian with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# Tank#: 5 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 TA050 1127 XERXES lf'Ym",complete ane page foreachcomparwacut DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 4/7/1999 3,000 ADDITIONAL DESCRIPTION(For local use my) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ® 1 a.REGULAR UNLEADED ❑2.LEADED ❑5.JET FUEL (Ifmww complete Peholcm Type) ❑ 1b.PREMIUM UNLEADED ❑3.DIESEL ❑6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ lc.MIDGRADE UNLEADED ❑4.GASOHOL 99.OTI)ER ❑3.CHEMICAL PRODUCT ❑ COMMON NAME(0om Hazardous Materials lweotory page) 441 CAS#(n.Hazardous Materials lmmtory page) M2 C]4.HAZARDOUS WASTE (luchides Und Oil) ❑95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑3.SINGLE WALL WITH ❑5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chok nae iumo*) 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 (Check one dem only) ❑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 (Check ooe iteum may) ❑2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑99.OTHER ❑5.CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED 3.EPDXY LINING 447 OR COATING ❑ ® 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED (Chi one imm X5) ❑2 ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99.OTHER (For local use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC q{q PROTECTION IF APPLICABLE PROTECTION ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED (Cbcck ane*m only) ❑4 IMPRESSED CURRENT E]99 OTHER ❑2 SACRIFICIAL ANODE (per local on only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chcck a0 the ) ❑ 1 SPILL CONTAINMENT 1,999,00 ❑ 1 ALARM ❑3 FILL TUBE SHUT OFF VAL` ❑ 2 DROP TUBE ❑ 2 BALL ❑4EXEMPT ❑ 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A description of the monitoring w poo shag be submitted to the local agency.) IF SINGLE WALL TANK(Cheek aU that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 1 VISUAL EXPOSED PORTION ONLY) (C�OOC item only) ❑ ( ❑ 5 MANUAL TANK GAUGING(MIG) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑ 1 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 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑No UPCF(12/99 revised)