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r 0 MIPIFIED PROGRAM CONSOLIDATED FORf� TANK: TA0505682 /J PR#: PR0231911 UNDERGROUND STORAGE TANKS - TANK PAGE 1 I FAC 4: FA0000540 0 I tpl l VVV per tank) (two pages p TYPE OF ACTION 7' 1111 Page 2 of 7 (Check only item only) ❑ 1 NEW SITE PERMIT ❑ 4,�MFNDED PERMfI' ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT ($pcoily reason-f r kxal use only) (Spccif,reason-For local use onlc) ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: __[T COUNTRYSIDE MINI MART 3 FA0000540 PR0231911 LOCATION WITHIN SITE(optimal) 14971 N HWY 88,LODI 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#: 4 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes No 434 TA0505682 MODERN If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 5/23/1995 12:00:OOAM 10,000 ADDITIONAL DESCRIPTION(For local use only) 438 H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ® 1 a.REGULAR UNLEADED ❑2.LEADED ❑ 5.JET FUEL (If marked complete Petroleum Type) ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ le.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 (Includes 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 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ® 2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERLSL-primary tank ❑ L 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 ❑ L 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/I00%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ L 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 (For local use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one item only) E] 4 IMPRESSED CURRENT E] 99 OTHER ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ❑ I SPILL CONTAINMENT 1,995.00 ❑ 1 ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT ❑ 3 STRIKER PLATE FLOAT W.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ (VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Chock one nem 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 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑No UPCF(12/99 revised)