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UqlrIED PROGRAM CONSOLIDATED FORIV TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Page_ol TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT R 5 CHANGE OF INFORMATION ❑O TEMPORARY SITE CLOSURE 7 PERMANENTLY CLOSED ON SITE (Check one item only) 430 ❑ 3 RENEWAL PERMIT (Spedfy reason-forlool use only) (Specifyreason-for local use only) ❑ e TANK REMOVED i BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID: FJ I 7-Eleven#14117 431 LOCATION WITHIN SITE(Optional) 2725 Count Club Dr., Stockton, C I:TANK DESCRIPTION {A scaled A plot plan whin the location of the UST system inclutling buildings and landmarks shall be submitted to the local a enc . 433 COMPARTMENTALIZED TANK ❑Yes ® NO 434 TANK ID# a3z TANK MANUFACTURER 2 Total Containment If'Yes",complete we page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS --- NUMBER OF COMPARTMENTS a37 4/1998 10,000 438 ADDITIONAL DESCRIPTION(For local use only) 11.TANK CONTENTS 440 r USE 439 PETROLEUM TYPE R VEHICLE FUEL R 1a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL plete Petroleum Type) ❑1b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL UEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER442 ICAL PRODUCT CAS#(from Hazardous Materials Inventory page)COMMON NAME (from Hazardous Materials Inventory page)RDOUS WASTE Gasoline 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 R 2. DOUBLE WALL []4. SIGNLE WALL IN VAULT [199. OTHER TANK MATERIAL-primary tank ®1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL Cl 4. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE W/ [199.OTHER REINFORCED PLASTIC(FRP) 100%METHANOL TANK MATERIAL-secondary lark ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE El 95. UNKNOWN 445 (Check one item only) [12. STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑B. FRP COMPATIBLE R 99.OTHER REINFORCED PLASTIC(FRP) W1100%METHANOL ❑5. CONCRETE [110.COATED STEEL TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING ❑95.UNKNOWN 446 HEN ED aa7 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING R 6 UNLINED ❑99 OTHER ) (Check one Item only) 448 ED 449OTHER CORROSION ❑1 MANUFACTURED CATHODIC❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWNPROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER ly) (Check one item only) ❑2 SACRIFICIAL ANODE 452 SPILL AND ON YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all R 1 SPILL CONTAINMENT 1998 ❑1 ALARM R 3 FILL TUBE SHUT OFF VALVE that apply) R 2 DROP TUBE 1995 ❑2 BALL FLOAT ❑4 EXEMPT R 3 STRIKER PLATE 1998 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 (Check one item only) ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE R 2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING +(SIR) BIENNIAL TANK TESTING ❑99 OTHER IV.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE 467 455 ESTIMATED QUANTITY OF SUBSTANCE 456 ESTIMATED DATE LAST USED(YR/MO/ TANK FILLED WITH INERT MATERIAL? DAY) REMAINING El Yes ❑ No gallons UPCF (1/99 revised) Formerly SWRCB Form B