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vIFIED PROGRAM CONSOLIDATED FO" n D� TANK: TA0122305 �( PR#: PR0231223 UNDERGROUND STORAGE TANKS - T PAGE 1� FAC#: FA0002324 ^. (two pages per tank) TYPE OF ACTIONPage 4 of 7 (Check only item only) ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMIT CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE ' v ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: 1 MARIGOLD SHELL* 3 FA0002324 PR0231223 LOCATION WITHIN SITE(Optional) 6131 PACIFIC AVE,STOCKTON 431 PHONE 1.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#: 5 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes (:]No 434 TA0122305 If"Yes".complete one page for each compartmettt DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 12,000 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑ I.MOTOR VEHICLE FUEL ❑ Ia.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked complete Petroleum Type) ® lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ lc.MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) yyl CAS#(from Hazardous Materials Inventory page) I 4, ❑4.HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN HL TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 4+3 (Check one item only) 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 W1 (Check one item 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 44 (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 ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 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 449 PROTECTION IF APPLICABLE PROTECTION (Check one item only) E]4 IMPRESSED CURRENT ❑ 99 OTHER ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR FNSTALLE450 TYPE(local use only) 31 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check an that apply) ® I SPILL CONTAINMENT jL)Q.Q� 200 s �f ® 1 ALARM 1,990.003 FILL TUBE SHUT OFF VAL` ❑Y 2 DROP TUBE 1,990.00 ❑ 2 BALL 194 EXEMPT ❑X 3 STRIKER PLATE 1,990,00 FLOAT IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item only) ❑ 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 ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER 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)