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VIFIED PROGRAM CONSOLIDATED FO 1 TANK: TA0515548 / PR#: PR0516526 UNDERGROUND STORAGE TANKS -TANK PAG FAC#: FA0012659 (two pages per tank) Page 8 of I I TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CI-IANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check only item only) _._, _ _____ _- ❑ 7 PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT t'Pei ty r m-for la�al..only) 6pa-ify nct--tie teal asc only) ❑8 TANK REMOVED 430 BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: LOVES COUNTRY STORE 3 FA0012659 PR0516526 LOCATION WITHIN SITE(Optional) 1553 COLONY RD,RIPON 411 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 ❑YesNo 434 compartmentTA0515548 MODERN WELDING CO OF TE If"Yes",complete one page for each compartment DATE IN A ED YEARIMO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 4- 20,000 1 ADDITIONAL DESCRIPTION(Fa local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® I.MOTOR VEHICLE FUEL ❑ 1 a.REGULAR UNLEADED ❑ 2.LEADED ❑ S.JET FUEL (If marked complete Petrolemn Type) ❑ 1 b.PREMIUM UNLEADED ® 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ 1 c.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Invent CAS# from Hazardous Materials Invent a ❑ aYPaBa) 441 ( M page)8) q42 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 MATERIAL-primary tank ® I.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Check one itenonly) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ I.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 44, (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 ❑ I.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING447 OR COATING ❑95.UNKNOWN 446 DATE INSTALLED (Check one item only) ❑ 2 ALKYD LINING ❑4 PHENOLIC LINING ® 6 UNLINED ❑ 99.OTHER (For teal me only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC k3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one item only) E] 2 SACRIFICIAL ANODE E] 4 ly) E] 4 IMPRESSED CURRENT �.99 OTHER E] 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 ® 1 ALARM 2,000.00 x 3 FILL TUBE SHUT OFF VAL' ❑x 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 loan agency.) IF SINGLE WALL TANK(Check a0 that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item may) ❑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 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑Yes ❑ No UPCF(12/99 revised)