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NIFIED PROGRAM CONSOLIDATED FO n TANK: TA0515545 I�,(/ PR#: PR0516526 UNDERGROUND STORAGE TANKS -TANK P 1 FAC#: FA0012659 (two pages per tank) Qj Page 2 of 11 TYPE OF ACTION ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check only item only) 19 i''10"ro i'9°Ji' ❑ 7 PERMANENTLY CLOSED ON SITE i 3 RENEWAL PERMIT ❑8 TANK REMOVED 4?0 BUSINESS NAME(Same as FACB.ITY NAME a DBA-Doing Business As) FACILITY ID: PR#: LOVES COUNTRY STORE 3 FA0012659 PR0516526 LOCATION WITHIN SITE(Optional) 1553 COLONY RD,RIPON 41 PHONE I.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 1D# Tank#: I 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes XNo 434 TA0515545 MODERN WELDING CO OF TE If-Yes",complete one page fa each compartment DATE INS D( AR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 4,7 18113 01 20,000 1 ADDITIO DESCRIPTION(For local use only) 433 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 IN 1.MOTOR VEHICLE FUEL ® T a.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (ItmarkedorntpletePetroleum Type) ❑ lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ I c 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 1T1.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check me item only) EXTERIOR MEMBRANE LINER E395.UNKNOWN M 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 (Chale 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 ❑ S.CONCRETE TANK INTERIOR LINING ❑ RUBBER LINED 1. 3.EPDXY LINING 447 OR COATING ❑ ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED (Chale one item only) ❑ 2 ALKYD LIFTING ❑ 4 PHENOLIC LINING ® 6 UNLINED ❑ 99.OTHER (For Iacal use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC 449 PROTECTION IF APPLICABLE PROTECTION 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED (Check we itern only) E] 4 IMPRESSED CURRENT :F99 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 2,000,00 ® I ALARM 2,000.003 FILL TUBE SHUT OFF VAL' ❑Y 2 DROP TUBE 2,000.00 ® 2 BALL 2,000,00 4 EXEMPT ❑X 3 STRIKER PLATE 2,000.00 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 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check me man 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)