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COMPLIANCE INFO_1985-1997
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2300 - Underground Storage Tank Program
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PR0231074
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COMPLIANCE INFO_1985-1997
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Last modified
3/1/2023 9:09:44 AM
Creation date
6/23/2020 6:40:52 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
1985-1997
RECORD_ID
PR0231074
PE
2361
FACILITY_ID
FA0002541
FACILITY_NAME
7-ELEVEN INC #20632
STREET_NUMBER
4627
STREET_NAME
DA VINCI
STREET_TYPE
DR
City
STOCKTON
Zip
95207
APN
11002003
CURRENT_STATUS
01
SITE_LOCATION
4627 DA VINCI DR
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
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SJGOV\rtan
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\MIGRATIONS\UST\UST_2361_PR0231074_4627 DA VINCI_1985-1997.tif
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EHD - Public
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�90UR e. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W y p <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B <br /> COM E A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY F7 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED ' <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: qt2 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.sF n 2�3 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: l Q►IC <br /> II.TANK gANTENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C• ❑ 1 UNLEADED 3 DIESEL ❑ <br /> A. 6 AVIATION GAS <br /> 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT 1b PREMIUM ❑ 4 GASAHOL 7 METHANOL <br /> UNLEADED 5 JET FUEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 6aVU/5 S L C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C,AND ALL THAT APPLIES IN BOX D AND E <br /> A. TYPE OF F-1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER El 95 UNKNOWN <br /> SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE F-] 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNO E] 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION LV 91 NONE ❑95 UNKNOWN ❑ 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVEGR OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A2 RESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 1 INGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 AARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U GALVANIZED STEEL A U 10 CATHODI PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 3 INTERSTITIAL99 OTHER <br /> MONITORING ❑ <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING EV4 AUTOMATIC TA UGING ❑ 5 GROUNDWATER MONITORING <br /> E::] 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING E] 91 NONE E:] 95 UNKNOWN �� ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO ❑ <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (PRINTED d SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# �FAr.n ITY� TANK# IL <br /> STATE I.D.# J <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS f <br /> FORM 8 (12-91) � FOR0034B-R6 <br /> CAC' ���' <br />
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