COMPLIANCE INFO_1988-2004 - Laserfiche WebLink

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IFIED PROGRAM CONSOLIDATED FORM ANK. TA0235503 1 PR#: PRO232355 UNDERGROUND STORAGE TANKS -TANK PAGE FAC#: FA0000591 (two pages per tank) ' TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMITPage 6 of 7 ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check only item only) 4 1 § `E ') ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT , IRIM S^= ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: I QUIK STOP MARKETS INC#1152 3 FA0000591 PR0232355 ITM LOCATION WITHIN SITE(optional) 1721 S CHEROKEE LN 1,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#: 3 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK El Yes g No 434 TA0235503 /`ce le)(,i`S` If"Yes",mmplete one page for each compartmrnt. DATE INSTALLFDD(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 /qff1j.i ceo,6w✓z 8,000 1 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PET OLEUM TYPE ® 440 ❑ 2.LEADED ❑ 5.JET FUEL 1.MOTOR VEHICLE FUEL la.REGULAR UNLEADED (If marked mrnpletc Petroleum Type) lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ lc.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) ❑ 4.HAZARDOUS WASTE ,/I '4 f (�/J �° Cl 442 (Includes Used Oil) /�i° N�t�.t.�v1 tyL/„ok id �S-L �®�'""Ci ❑ 95.UNKNOWN Qc,-Fqa IH.TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one itcm 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 U18.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 FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ ❑3.EPDXY LINING 447 OR COATING 1.RUBBER LINED ❑ 5.GLASS LINING ❑95.UNKNOWN aa6 DATE INSTALLED (Check one item only) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING 5K6 UNLINED ❑99.OTHER (For local use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN -8 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one it=only) ❑ 4 IMPRESSED CURRENT ❑ 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 SPILL CONTAINMENT j 9k ❑ 1 ALARM Ll!f3 FILL TUBE SHUT OFF VAL %U (Check all that apply) � [e2 DROP TUBE 17,?17 ❑ 2 BALL ❑ 4 EXEMPT N[ '3 STRIKER PLATE �-w - FLOAT 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 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Chock one 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 (SIR)BIENNIAL TANK TESTING ❑3 MANUAL MONITORING ❑ 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)