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•IFIED PROGRAM CONSOLIDATED FO I ( Q KS UNDERGROUND STORAGE TANKS - TANK P CUtl tv(two nk) Page Z of Z TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 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) 3 FACILITY ID: 1 Quik Stop Market#124 LOCATION WITHIN SITE(Optional) 431 ANIS f? "TItt3°`{A scald pdt plat wltll the locallon taf tthe UST system ireltirtgldirigs e[�d this shall t slmlttsel e, 1 TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 1 Xerxes If"Yes",complete one page for each compartment. DATE INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 (YEAR/MO) 1985/January 10,000 1 ADDITIONAL DESCRIPTION(For local use only) 438 11:TANK C hNTENTS b. , r TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL 19 1a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) ❑1 b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER_ ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE Unleaded Gasoline (Regular, 87 Octane) 8006-61-9 (Includes Used Oil) ❑95.UNKNOWN Ill. TAN :G01+161WCTION : "' TYPE OF TANK ❑1. SINGLE WALL ❑3.SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER [195. UNKNOWN ®2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE [195. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE W/ ❑99.OTHER REINFORCED PLASTIC(FRP) 100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL [14.STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE ❑99.OTHER REINFORCED PLASTIC(FRP) W/100%METHANOL ❑5. CONCRETE [110.COATED STEEL TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHERCORROSION ❑1 MANUFACTURED CATHODIC❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 only) (Check all ®1 SPILL CONTAINMENT 1998 ❑1 ALARM ®3 FILL TUBE SHUT OFF VALVE,117f that apply) - ®2 DROP TUBE 1998 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 1985 _ IIi.:TANKLEAK DETEC' ON,A deseripiior'pfithe monit5l[tn4oogratnshall6e s4ti itte to the]oval-agency,} ` IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ®2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING +(SIR) BIENNIAL TANK TESTING ❑99 OTHER IT xTANK t?SURENFAT1t �R.Nfa?1NF1T Cl{? #lR1 PLACE' ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE 456 1 TANK FILLED WITH INERT MATERIAL? 457 REMAINING UPCF (1/99 revised) Formerly SWRCB Form B