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6 n' UN FLED PROGRAM CONSOLIDATED FO a 103 , TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (Two pages per tank) Page 2 of 7 TYPE OF ACTION ❑ L NEW PERMIT ❑ 4.AMENDED PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY TANK CLOSURE 430. (Check ane item only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENTLY CLOSED ON SITE (Specify reason) (Specify meson) ® 8.TANK REMOVED BUSINESS NAME(Sam,as FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY ID: 1. LOCATION WITHIN SITE(optional) 431. Country Club Shell, 2575 Country Club Blvd., Stockton,CA 95204 I.TANK DESCRIPTION (A scaled plot planwith the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID#-'q_666bOC)-4 432 TANK MANUFACTURER 433. COMPARTMENTALIZED TANK ❑Yes ® No 434. Xerxes o-yes,"complete one page for each comp roment. DATE INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS 437 (YEAR/MO) 1995 15,000 NA ADDITIONAL DESCRIPTION(For local use only) 438. II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440. ® 1. MOTOR VEHICLE FUEL ® la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifchecked,complete Petroleum Type) ❑ Ib. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION GAS ❑ 2. NON-FUEL PETROLEUM ❑In. MIDGRADEUNLEADED [14. GASOHOL ❑99.OTHER: ❑ 3. CHEMICAL PRODUCT COMMON NAME (fmm Haeardous Materials Inventory page) 441. CAS#(from Hmardeas Materials Inventory page) 442. ❑ 4. HAZARDOUS WASTE NA NA (Includes Used On) ❑ 95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL ❑3. SINGLE WALL WITH EXTERIOR ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443. (Check one item only) MEMBRANELINER 095. UNKNOWN ®2. DOUBLE WALL ❑4. SINGLE WALL IN A VAULT [:199. OTHER TANK MATERIAL-primary Ink ❑1. BARE STEEL 293. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95.UNKNOWN 444. (Check one item only) ❑2. STAINLESS STEEL [:14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE [199.OTHER: REINFORCED PLASTIC FRP W/100%METHANOL TANK MATERI -secondary tank ❑1. BARE STEEL 3. FIBERGLASS/PLASTIC AL ® 08. FRP COMPTIBLE W/100%METHANOL ❑95.UNKNOWN 445. (Check one item only) [12. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [19. FRP NON-CORRODABLE JACKET ❑99,OTHER REINFORCED PLASTIC(FRP) [110. COATED STEEL 135. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED ❑3.EPDXY ❑ LINING ❑5.GLASS LINING [195.UNKNOWN 446. DATE INSTALLED 447. OR COATING [12.ALKYD LINING ❑4.PHENOLIC LINING ®6.UNLINED [199.OTHER Check one item only) OTHER CORROSION ❑1.MANUFACTURED CATHODIC 93.FIBERGLASS REINFORCED PLASTIC [195.UNKNOWN 448, DATE INSTALLED 449. PROTECTION PROTECTION [14.IMPRESSED CURRENT [199.OTHER IfA licable ❑2.SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED 450. TYPE 451. OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452. (Check all that apply) ❑ 1.SPILL CONTAINMENT ❑1.ALARM ❑3.FILL TUBE SHUT OFF VALVE [12.DROP TUBE ❑2.BALL FLOAT ❑4.EXEMPT ❑3.STRIKER PLATE IV.TANK LEAK DETECTION (A description of the monitoring tymaram,shall be submitted to the local agency) IF SINGLE WALL TANK d53. IF DOUBLE WALL TAMC OR TANK WITH BLADDER 454. (Check a0 that apply) (Check one item only) ❑ I. VISUAL(EXPOSED PORTION ONLY) [15.MANUAL TANK GAUGING(MTG) [:11.VISUAL(SINGLE WALL IN VAULT ONLY) ❑2. AUTOMATIC TANK GAUGING(ATG) ❑6.VADOSE ZONE [12.CONTINUOUS INTERSTITIAL MONITORING ❑3. CONTINUOUS ATG [17.GROUNDWATER [13.MANUAL MONITORING [14. STATISTICAL INVENTORY RECONCILIATION [18.TANK TESTING (SIR)+BIENNIAL TANK TESTING 099. 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? 45T gallons ❑Yes ❑ No UPCF hwfwrc-b(1/99)-1/4 http://w".unidocs.org � Rev.02/16/00