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FIED PROGRAM CONSOLIDATED FORM TA 'K: RO231094 UNDERGROUND STORAGE TANKS -TANK GE i a� FAC#: F tank) 47 tan (two pages per k) Page 2 of 7 TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑6 TEMPORARY SITE CLOSURE (Check only item only) +^-" :s' 'x a,y ''r `` e '+g ❑ 7 PERMANENTLY CLOSED ON SITE 430 ..,.f �. �;,, 3 ❑8 TANK REMOVED ❑ 3 RENEWAL PERMIT s�.� .., ) a ..; *� .fix BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID" PR#: 1 SHELL FOOD MART* 3 FA( 447 PR0231084 LOCATION WITHIN SITE(Optional) 2320 N EL DORADO ST.STOCKTON 9 S Z 0( 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 TANKVMANUFFACTURER 433 COMPARTMENTALIZED TANK El Yes No 434 TA0108105 !� ArR_Xb, 3 tf•Yes•.eompktem pWfmcachconparnum DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS i36 NUMBER OF COMPARTMENTS 437 o >2 000 1 439 ADDITIONAL.DESCRIPTION(For local use only) If.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 400 I.MOTOR VEHICLE FUEL la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL ,matted complete Fctrokmn Type) ❑ I b.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Imesaypage) 441 CA$#(from Hazardous Materials Imemory page) 442 ❑ 4.HAZARDOUS WASTE (Inclodcs 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 EXTERIOR MEMBRANE LINER [:]95.UNKNOWN (check one item only) 2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑99.OTHER TANK MATERIAL-primary tank ❑ L.BARE STEEL FIBERGLASS/PLASTIC ❑ S.CONCRETE ❑ 95.UNKNOWN 444 (Check ant item only) ❑ 2.STAINLESS STEEL 0 STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE Wi 100%METHANOL REINFORCED PLASTIC(FRP) ❑99.OTHER TANK MATERIAL-secondary tank ❑ L BARE STEEL � FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (Check one item only) ❑ 2.STAINLESS STEEL u 4_STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑99.OTHER ❑ 5.CONCRETE 447 TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED OR COATING ❑99.OTHER (Check om item only) ❑ 2 ALKYD LINING ❑4 PHENOLIC LINING I�L6 UNLINED (For local use only) 449 OTHER CORROSION ❑ I MANUFACTURING CATHODIC FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 449 DATE INSTALLED PROTECTION IF APPLICABLE PROTECTION 4 IMPRESSED CURRENT ❑ 99 OTHER (Cheekoncitcmonly) ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE45o TYPE(focal useon(y) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 I p �(;�+� (Check all that apply) I SPILL CONTAINMENT ( ! 0 ]ALARM 19& �3 FILL TUBE SHUT OFF VAL' 2 DROP TUBEQ ] 2 BALL LlJ 4 EXEMPT 3 STRIKER PLATE / �/�j 0 FLOAT IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 IF SINGLE WALL TANK(Check all that apply) (Check one item only) ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER V2 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 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIA(;! 457 ESTIMATED DATE LAST USED(YR/MO/DAY) ❑ Yes ❑ No UPCF(12/99 revised)