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u tetrrc✓ rnvcantsrvt vureavu✓rt cu rvnivt , �.,� TANKS UNDER&OUND STORAGE TANKS ANK PAGE 1 r (two pages per tank) Page_of TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ® 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business FACILITY ID: t 3 Valero Corner Store #3698 / 3 8 / $7 LOCATION WITHIN SITE(Ootiona1 431 I.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# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 3698-1 I Modern If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 1435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1/87 10152 ADDITIONAL DESCRIPTION(For local use only) 436 11.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL ® 1a. REGULAR UNLEADED ❑2. LEADED [15. JET FUEL (If marked complete Petroleum Type) ❑lb. PREMIUM UNLEADED [13. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑1c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materiels Inventory page) aa1 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE 8006-61-9 (Includes Used OII) ❑95.UNKNOWN Ill. 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 095. UNKNOWN 02. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank 01. BARE STEEL [13. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/ ❑99.OTHER REINFORCED PLASTIC(FRP) 100%METHANOL TANK MATERIAL-secondarytank ❑1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 0 5. CONCRETE [395. UNKNOWN 445 (Check one item only) [12. STAINLESS STEEL ®4.STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE ❑99.OTHER REINFORCED PLASTIC(FRP) W/100%METHANOL ❑5. CONCRETE [110.COATED STEEL TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING [195.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one Item only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all ®1 SPILL CONTAINMENT that apply) 2004 Phil Title ®1 ALARM ❑3 FILLTUBE SHUT OFF VALVE ®2 DROP TUBE 2004 Phil Title ®2 BALL FLOAT ❑4 EXEMPT 03 STRIKER PLATE 1/87 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 ®2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8TANK TESTING +(SIR) BIENNIAL TANK TESTING 0 9 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE'` ESTIMATED DATE LAST USED YR/MO/DAY TANK FILLED WITH INERT MATER ( ) 455 ESTIMATED QUANTITY OF SUBSTANCE 456 MATERIAL? 457 REMAINING gallons El Yes ❑ No UPCF(1/99 revised) Formerly SWRCB Form B