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I rd IFIED PROGRAM CONSOLIDATED FOR 3 (� ANK: TA0505426 PR#: PR0231801 UNDERGROUND STORAGE TANKS -TANK PA FAC#: PR0231801 I"t (two pages per tank) Page 2 of 9 TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION E] 6 TEMPORARY SITE CLOSURE (Check only item only) [:] 7 PERMANENTLY CLOSED ON SITE E]3 RENEWAL PERMIT Elmo ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME a DBA-Doing Business As) FACILITY ID: I PR#: 1 COUNTRY MART DIESEL&GAS 3 FA0003290 PR0231801 LOCATION WITHIN SITE(Optional) 34243 S CHRISMAN RD,TRACY 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 TA0505426 TRUSCO lf'Tes",complete one page for each mmpamrent. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1/1/1995 12,000 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ❑ I a.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked complete Petroleum Type) ❑ lb.PREMIUM UNLEADED ® 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ 1 c.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) 441 CAS#(flan Hazardous Materials inventory page) 442 ❑ 4.HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN HI.TANK CONSTRUCTION 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 ❑ 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 444 (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 445 (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 (Fm 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) ❑ 4 IMPRESSED CURRENT ® 99 OTHER ❑ 2 SACRIFICIAL ANODE (For lural use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ® 1 SPILL CONTAINMENT ❑ 1 ALARM ® 3 FILL TUBE SHUT OFF VAL` ❑x 2DROP TUBE ❑ 213ALL ❑ 4EXEMPT ❑?C 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A description o£the monitoring program shall be sobndtted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check me 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)