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I �o� IED PROGRAM CONSOLIDATED FORM T : TA0515769 PR#: PRO231760 UNDERGROUND STORAGE TANKS - TANK PAGE 1 FAC#: FA0003831 (two pages per tank) TYPE OF ACTION Page 4 of 5 (Check only hem only) ❑ I NEW SITE PERMIT ❑4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑6 TEMPORARY SITE CLOSURE ❑7 PERMANENTLY CLOSED ON SITE ❑3 RENEWAL PERMIT (Specify reason-for local use Dole) (Specify reason-for local use only) ❑g TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: 1 WATERLOO SHELL* 3 FA0003831 PR0231760 LOCATION WITHIN SITE(opeone) 4315 WATERLOO RD,STOCKTON 431 PHONE L TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# Tank#: 9 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK [:]Yes ❑No 434 TA0515769 XERXES If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 417 1/1/2005 12:00:OOAM 12,000 1 ADDITIONAL DESCRIPTION(For local use only) 439 11.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL a. UNLEADED ❑2.LEADED ❑5.JET FUEL (If marked complete Petroleum Type) :X:Ib.P IUM UNLEADED ❑3.DIESEL ❑6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM c.MIDGRADE UNLEADED ❑4.GASOHOL ❑99.OTHER ❑3.CHEMICAL PRODUCT 4.HAZARDOUS WASTE COMMON NAME(from Hamrdous Materials Inventory page) 441 CAS#(from Hamrdous Materials Inventory page) 442 ❑ (Includes Used Oil) ❑95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑3.SINGLE WALL WITH ❑5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LIVER ❑95.UNKNOWN X❑2 DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑99.OTHER TANK MATERIAL-primary tank ❑ I.BARE STEEL ❑FIBERGLASS/PLASTIC ❑5.CONCRETE ❑95.UNKNOWN 444 (Check one item only) ❑2.STAINLESS STEEL ❑STEEL CLAD W/FIBERGASS ®8.FRP COMPTIBLE W/1001%METHANOL REINFORCED PLASTIC(FRP) ❑99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑3.FIBERGLASS/PLASTIC ❑5.CONCRETE ❑95.UNKNOWN 445 (Check one item only) ❑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 ❑ L RUBBER LINED ❑3.EPDXY LINING E]5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED OR COATING (Check one item only) ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99.OTHER (For local use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 44' PROTECTION IF APPLICABLE PROTECTION (Check one item only) [j4 IMPRESSED CURRENT ❑99 OTHER ❑2 SACRIFICIAL ANODE (For tical use only) SPILL AND OVERFILL YEAR INSTALLE050 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that ® I SPIN.CONTAINMENT 2,005.00 ❑ 1 ALARM ® 3 FILL TUBE SHUT OFF VALv 2,005.00 apply) © 2 DROP TUBE 2,005,00 ❑2 BALL ❑4 EXEMPT ® 3 STRIKER PLATE 2,005.00 SAT IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) IF SINGE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) (Check one item only) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑ I VISUAL(SINGE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR)BIENNIAL TANK TESTING E]3 MANUAL MONITORING ❑99 OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 4D QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? +S7 1/1/2005 12:00:OOAM 55 ESTIMATE0.00 gallons ❑Yes ❑No UPCF(12/99 revised)