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IED PROGRAM CONSOLIDATED FO , • T UNDERGROUND STORAGE TANKS - TANK PAGE 19�ank) (two pages Page-q-of 7 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) 1 3 FACILITY ID: Quik Stop Market#148 LOCATION WITHIN SITE(Optional) 431 2 C)'5 L0C_V�e 4�0(-CA Lo4t f I.TANKDESCRIPTION (A scaled plot plan with the location of the LIST system including buildings and landmarks shall besubmitted to the local agency.) TANK ID# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 Xerxes If"Yes",complete one page for each compartment. DATE INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 (YEAR/MO) 1988/June 10,000 1 ADDITIONAL DESCRIPTION(For local use only) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®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 ID 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 [14. HAZARDOUS WASTE Unleaded Gasoline Mid rade, 89 Octane 8006-61-9 (Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3.SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER [195. UNKNOWN ®2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER_ TANK MATERIAL-primary tank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC [15. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ID 8. FRP COMPATIBLE W/ [199.OTHER REINFORCED PLASTIC(FRP) 100%METHANOL TANK MATERIAL-secondary tank ❑1. BARE STEEL [13. FIBERGLASS/PLASTIC [15. CONCRETE ❑95. UNKNOWN 445 (Check one item only) [12. STAINLESS STEEL [14.STEEL CLAD W/FIBERGLASS ISI 8. FRP COMPATIBLE ❑99.OTHER REINFORCED PLASTIC(FRP) W/100%METHANOL [15. CONCRETE [110.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 ❑4 PHENOLIC LINING ISI 6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC❑3 FIBERGLASS REINFORCED PLASTIC [:195 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 (Check all ®1 SPILL CONTAINMENT 1988 only) ❑1 ALARM 19 3 FILL TUBE SHUT OFF VALVE' J 793 that apply) ®2 DROP TUBE 1988 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 1988 _ IV.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 (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 ISI 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 _ IV.TANK CLOSYWINFORMATIO4-1 PERMME1 ;'CLO$URE IN P[AGS ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE 456 1 TANK FILLED WITH INERT MATERIAL? 457 REMAINING UPCF (1/99 revised) Formerly SWRCB Form B 5-L- 121111&0 lz. [00