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IED PROGRAM CONSOLIDATED FORN. TANK: TA0515646 PR#: PR0231118 UNDERGROUND STORAGE TANKS - TANK PAGE 1 FAC#: FA0003284 (two pages per tank) TYPE OF ACTION Page 4 of 7 (Check only item only) ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (S c tfv msson-for I:,.-�l use rn, ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT �` ) (Spccifi rt aso,-for loci use onl.) ❑g TANK REMOVED 430 BUSINESS NAME(Same as FACILRY NAME or DBA-Doing Business As) FACILITY ID. PR#: I AMM MART 19 GASOLINE 3 FA0003284 PR0231118 LOCATION WITHIN SITE(optional) 2185 E FREMONT ST,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 ID# Tank#: 5 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ® Yes ❑No 434 TA0515646 MODERN If"Yes'.complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 4/13/2004 12:00:OOAM 5,000 3 ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ❑ I a.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (Ifmarked complete Petroleum Type) ® I b.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ I c.MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials inventory page) 441 CAS#(from Iiaz>tdous Materials Inventorypage) 442 E]4.HAZARDOUS WASTE (Includes Used Oil) ❑95.UNKNOWN 1H.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 ®2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑ 99.OTHER _1 TANK MATERIAL-primary tank ® 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 444 (Check one item 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 (Check one item only) ❑2.STAINLESS STEEL ❑ 4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTBLE W/l00%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING (Check one item only) ❑2 ALKYD LINING ❑ 4 PHENOLIC LINING ®6 UNLINED ❑99.OTHER (For kcal use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ® 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one item only) ❑4 IMPRESSED CURRENT ❑ 99 OTHER ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apph) N I SPILL CONTAINMENT 2,002.00 PHL-TITE ® I ALARM 2,002.00 ❑ 3 FILL TUBE SHUT OFF VAL` FYI 2 DROP TUBE 2,002.00 OPW 61 N 2 BALL 2,002.00 ❑4 EXEMPT 3 STRIKER PLATE 2,002.00 MODERN FLOAT rV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local age--.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item cal)) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ 1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑3 CONTINUOUS ATG ❑ 7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING (SIR)BIENNIAL TANK TESTING E]3 MANUAL MONITORING ❑ 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 MATERIAL? 457 ❑Yes ® No UPCF(12/99 revised)