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1 PIED PROGRAM CONSOLIDATED FORM TANK: TA0515737 /9 <br /> PR N: PRO523176 .x je,4 <br /> UNDERGROUND STORAGE TANKS - TANK PAGE1 �D)i FAC#: FA0015646 w�, <br /> (hoo pages per tank) All <br /> TYPE OF ACTION <br /> (Cbppy my��,) ❑ INEW SUE PERMIT ❑ 4AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION Psge2 of3 <br /> ❑6 TEMPORARY SITE CLOSURE <br /> ❑ 7 PERMANENTLY CLOSED ON SUE <br /> ❑ 3RENEWAL PERMIT (Sp0C1Cy'1e0pcn-rerlo ..*) (Spairy.-r«kmlanmy) <br /> ❑STANK REMOVED 430 <br /> BUSINESS NAME(Sme.FACIJry NAME«DBA-Dwj ea.imv A:) FACILITY ID: PR#: ) <br /> PANSKI PROPERTY 3 FA0015646 PRO523176 <br /> LOCATION WITHINSrfE(opn-) 121 S CHEROKEE LN,LODI 431 <br /> PHONE <br /> L TANK DESCRIPTION(A scaled plot pled with the location of the UST system imluding buildings and la¢dmarks shall be submitted to the local agal3cyJ <br /> TANK ID# Tarn[#: 1 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 <br /> TA0515737 true,cmpim ar page r«�wa«.tet. <br /> DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 <br /> 500 <br /> ADDITIONAL DESCRIPTION(F«bW uoc my) <br /> 439 <br /> TANK USE 439 PETROLEUM TYPE d TANK CONTENTS <br /> ® L MOTOR VEHICLE FUEL ® la.REGULAR UNLEADED ❑ 2.LEADED <br /> ❑5.JET FUEL <br /> (If a anwkte Pmolnm Type) ❑ Ib.PREMIUM UNLEADED ❑3.DIESEL ❑ 6.AVIATION FUEL <br /> ❑2.NON-FUEL PETROLEUM ❑ le MIDGRADE UNLEADED <br /> ❑3.CHEMICAL PRODUCT ❑4.GASOHOL ❑ 99.OTHER <br /> ❑4.HAZARDOUS WASTE COMMON NAME(Boo,x,mems mmi.b mmasy page) 44i CAS#(ban x„�ems Mataiw immmy page) aez <br /> omm«Draw) <br /> ❑95.UNKNOWN <br /> HL TANK CONSTRUCTION <br /> TYPE OF TANK ® 1.SINGLE WALL ❑ 3.SINGLE WALL WITH <br /> ❑5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 <br /> (CR«Y arum my) EXTERIOR MEMBRANE LINER [:195.UNKNOWN <br /> ❑2,DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑99.OTHER <br /> TANK MATERIAL-primary taM M 1.BARE STEEL ❑ FIBERGLASS/PLASTIC <br /> ❑5.CONCRETE ❑ 95.UNKNOWN 444 <br /> (C3 me,t only) ❑ 2.STAINLESS STEEL ❑STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100.METHANOL <br /> REINFORCED PLASTIC(FRP) ❑ 99 OTHER <br /> TANK MATERIAL-secondary tmik ® L BARE STEEL ❑ 3.FIBERGLASS/PLASTIC <br /> ❑5.CONCRETE ❑ 95.UNKNOWN 445 <br /> (Chas ar ilm my) ❑2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ S.FRP COMPTIBLE W/100'A METHANOL <br /> REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER <br /> ❑ 5.CONCRETE <br /> TANK INTERIOR LINING RU <br /> 1. BBER LINED M7 <br /> OR COATING ❑ ❑3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED <br /> IChakme uma0yl ❑ 2 ALKYD LINING ❑4 PHENOLIC LINING ® 6 UNLINED ❑ W.OTHER <br /> (F«br .mly) <br /> OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC µq <br /> PROTECTION IF APPLICABLE PROTECTION ❑ 3 FIBERGLASS REINFORCED PLASTIC ® 95 UNKNOWN UR DATE INSTALLED <br /> (Chale meama6v) El IMPRESSED CURRENT ❑99 OTHER <br /> E] 2SACRDTCW,ANODE (F«bmlismy) <br /> SPILL AND OVERFILL YEAR INSTALLL450 TYPE0eW.mly) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 <br /> (ChakeVUuappy) ❑ 1 SPILLCONTAINMENT ❑ I ALARM <br /> ❑ ❑ 3 FILL TUBE SHUT OFF VAL` <br /> 2 DROP TIME2 BALL <br /> ❑ 3STRIKER PLATE E] FLOAT <br /> ❑ 4EXEMPT <br /> N.TANK LEAK DETECTION(A&.46m ortm amilamg« .e Icavm umelaW Ymcy.) <br /> IF SINGLE WALL TANK(C w W Wy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 <br /> ❑ 1 VISUAL(EXPOSED PORTION ONLY) El MANUAL TANK GAUGING(MTG) (Ch«komsma4y) <br /> ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ® 1 VISUAL(SINGLE WALL IN VAULT ONLY) <br /> ❑3 CONTINUOUS ATG ❑ 7 GROUNDWATER ❑2 CONTINUOUS INTERSTITIAL MONITORING <br /> ❑4 STATISTICAL INVENTORY RECONCILIATION [19 TANK TESTING <br /> (SIR)BIENNIAL TANK TESTING ❑ 990THER 3 MANUAL MONITORING <br /> V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE <br /> ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 <br /> 1/1/1960 12:00:OOAM 0.00 gallons ❑Yes ❑ No <br /> UPCF(12/99 revised) <br />