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lffift� 11111111111k (,/I;? Dom' IED PROGRAM CONSOLIDATED FO ' ( OU TANKS UNDERGROUND STORAGE TANKS - TANK PA 1 6-I lu� U (two pages per tank) Pageof,}_ 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#121 LOCATION WITHIN SITE(Optional) 431 1.TANK DESCRIPTIONT{A,sc of b[��Cttt th�,'lacation a US m including,bull,, TAN ID#y y"�� (� 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No a3a 5 -F/1 � 0� / Xerxes If"Yes",complete one page for each compartment. DATE INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 (YEAR/MO) 1998/April 12,000 1 ADDITIONAL DESCRIPTION(For local use only) 438 q 11.WANK CONTENTS TANK USE 439 PETROL EUM TYPE aao ®1. MOTOR VEHICLE FUEL ®1a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) ❑1b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL [12. 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 -,z III. TANK C!*$TRUgWN -V' . TYPE OF TANK ❑1. SINGLE WALL [:13.SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ID 2. DOUBLE WALL [14. SIGNLE WALL IN VAULT [199. OTHER_ TANK MATERIAL-primary tank [11. BARE STEEL ❑3. FIBERGLASS/PLASTIC [15. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE W/ ❑99.OTHER REINFORCED PLASTIC(FRP) 100%METHANOL TANK MATERIAL-secondary tank [11. BARE STEEL [13. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ®8. FRP COMPATIBLE ❑99.OTHER REINFORCED PLASTIC(FRP) W/100%METHANOL [15. CONCRETE ❑10.COATED STEEL TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING [:14 PHENOLIC LINING 196 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑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 ISI 3 FILL TUBE SHUT OFF VALVE that apply) - ®2 DROP TUBE 1998 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 1998 _ Pr4pr rpM SII be 9llbtl tted ci the local agency} �- ,E , 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 - _!t ' KA 949,EJOFQR, 9a.A IENT LOSURE�N# ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE 456 TANK FILLED WITH INERT MATERIAL? 457 REMAINING UPCF (1/99 revised) Formerly SWRCB Form B