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IFIED PROGRAM CONSOLIDATED FO lJ TANK: TA0515546 PR#: PR0516526 UNDERGROUND STORAGE TANKS -TANK P GE 1 FAC#: FA0012659 (two pages per tank) Page 4 of 11 TYPE OF ACTION ❑ I NEW SITE PERMIT ❑ 4A',11 LADED PERM]I" ❑ 5 CHANGE OF INFORMATION ❑6 TEMPORARY SITE CLOSURE (Chock only item only) ❑ 7 PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT (Spcoitvrcasat-forlocalmeonly) (Spcifyrctsat-forloculweaniy) ❑8TANK REMOVED 430 BUSINESS NAME(Sane as FACQ.rCY NAME or DBA-Doing Business As) FACILITY ID: PR#: LOVES COUNTRY STORE FA0012659 PR0516526 LOCATION WITHIN SITE(optionai) 1553 COLONY RD,RIPON 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#: 2 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes ❑No 434 TA0515546 MODERN WELDING CO OF TE If"Yes",complete one page foreach cotpamrent. DATE INST LED( AR/MO) 035 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 2`) 8,000 2 ADDITIO DESCRIPTIO (For local use only) 438 U.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® I.MOTOR VEHICLE FUEL ® la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked complete Petroletmn Type) ❑ I b.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 Invrntoy page) 442 ❑4.HAZARDOUS WASTE (Includes Used oil) ❑ 95.UNKNOWN M.TANK CONSTRUCTION TYPE OF TANK ❑ I.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 ❑ S.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 ❑ S.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 lokal use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN �g DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one item may) [:]4 IMPRESSED CURRENT gr99 OTHER ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(Iota]use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) N I SPILL CONTAINMENT 2,000.00 N 1 ALARM 2,000.00 X 3 FILL TUBE SHUT OFF VAL` 0 2 DROP TUBE 2,000.00 ® 2 BALL 2,000.00 ❑4 EXEMPT Q 3 STRIKER PLATE 2,000.00 FLOAT rV.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 ❑ STANK 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)