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IFIED PROGRAM CONSOLIDATED FO &//,f1E7 70Q TANK: TA0515702 PRN: PRO521942 UNDERGROUND STORAGE TANKS -TANK PAGE 1 FAC#: FA0014921 (two pages per tank) Page 2 of 5 TYPEOFACTION ❑ INEW SITEPERMIT ❑ 4AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (CN«k�nly iainaNy) ❑ 7PERMANENTLY CLOSED ON SITE (Sp«iry mav«-f«1«Nvu mH) (Spo iry.-f«I«dmecdy) STANK REMOVED 430 ❑ 3 RENEWAL PERMIT -:.? ❑ BUSINESS NAME(Sameu FACILITYNAME«DBk TY ID'. PR#: 1 RANCHO SAN MIGUEL MARKET' FA001492 t PR0521942 LOCATION WITHIN SITE(Opdonm 1427 AIRPORT WAY,STOCKTON 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 IDI! Tank#: I 432 TANK MANUFACTURER 453 COMPARTMENTALIZED TANK ®yes [IN, 434 TA0515702 K&T STEEL If^Y.a'eeoWme«re"r«e«Lwmpemoea' DATE INSTALLED(YEAR/MO) 431TANK CAPACITY IN GALLONS 456 NUMIBEK OF COMIPAK I MIENTS 437 1/28/2004 12:00:OOAM 15 000 2 ADDITIONAL DESCRIPTION(F«tocal.«y) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL M la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (IfnnAWwmpk Peuoleum Type) ❑ Ib.PREMIUMUNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ le.MIDGRADE UNLEADED ❑4.GASOHOL ❑99.OTHER ❑ 3.CHEMICAI.PRODUCT COMMON NAME(fr«n Hvad«a Mwenels lmxnrory�pege) 441 CAS#(6cm Heaasdmu Mnmals[o,m« pagO 442 ❑4.HAZARDOUS WASTE (I«hdn Used Oil) ❑ 95.UNKNOWN UL TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Cleek oneimv any) EXTERIOR MEMBRANE LINER E]95.UNKNOWN ® 2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑99.OTHER TANK MATERIAL-primary tank ® 1.BARE STEEL ❑ FIBERGLASS/PLASTIC [15.CONCRETE ❑ 95.UNKNOWN 444 (Ch«k am iron 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 ❑ 5.CONCRETE ❑95.UNKNOWN 445 (Chxk one ilmsoNyl ❑ 2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ S.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ I.RUBBER LINED E] 3.EPDXY LINING E] 5,GLASS LINING E]95.UNKNOWN 44a DATE INSTALLED 441 OR COATING (LL J:acre nwoNy) ❑ 2ALKYD LINING ❑4PHENOLIC LINING ® 6UNLINED ❑ 99.OTHER (F«I«duce«oy) OTHER CORROSION ❑ I MANUFACTURING CATHODIC M3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATEINSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑ 990THER (Ch«ka«Iran«NI ❑ 2SACRIFICW.ANODE (F«lord use oNy) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(loceluseonly) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chink aI Ihn apply) ® I SPILL CONTAINMENT 2,004.00 OPW ® I ALARM ® 3 FILL TUBE SHUT OFF VAL`2,004.00 0 2DROP TUBE 2,004,00 OPW ®2BALL ❑4EXEMPT Q 3STRIKER PLATE 2,004.00 OPW FLOAT IV.TANK LEAK DETECTION(A a Pimee ad,e monuaneg waaree"Ire a a eel wmc I«.1 IF SINGLE WALL TANK(Chock a8 that appy) 453 IF DOUBLE WALL.TANK OR TANK WITH BLADDER 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Ch«kencitemoWy) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6VADOSE 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 MATERIA.? 457 ❑Yes ❑No UPCF(12/99 revised)