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L IED PROGRAM CONSOLIDATED FORM1p TANK: TA0515647 PR#: PRO231118 UNDERGROUND STORAGE TANKS - TANK PAGE 1 FAC#: FA0003284 (two pages per tank) TYPE OF ACTION Page 6 of 7 (Check onlv item only) ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE ❑ 7 PERMANENTLY CLOSED ON SITE I SNcifv reason-for local use oily) 1 Spccif,reason-fix local use only). ❑ 3 RENEWAL PERMIT ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: 1 EAST FREMONT MINI MART&GASOLINE 3 FA0003284 PR0231118 LOCATION WITHIN SITE(Optional) 2185 E FREMONT ST,STOCKTON 431 PHONE 1.TANK DESCRIPTION(A scaled plot plan yvith the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK fD# Tank#: 6 q32 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK M Yes ❑No 434 TA0515647 MODERN If"Yes",complete one page for each conpimment. DATE INSTALLED(YEAR/MO) 431 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 H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ❑ la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked 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) qq I CAS#(from Hazardous Materials Inventon.page) 442 ❑4.HAZARDOUS WASTE (Includes 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 ® 2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ® 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Check one itern only) ❑2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/1008/6 METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ I.BARE STEEL ® 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (Check one item only) ❑ Z STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%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 local use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ® 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION E]) 4 IMPRESSED CURRENT ❑ 99 OTHER (Cheek one item only ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED '- (Check all that apply) M I SPILL CONTAINMENT 2,002.00 PHL-TITE ® I ALARM 2,002.00 ❑ 3 FILL TUBE SHUT OFF VAL` x❑ 2 DROP TUBE 2,002.00 OPW 61 ® 2 BALL 2,002,00 ❑ 4 EXEMPT 0 3 STRIKER PLATE 2,002,00 MODERN FLOAT 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 4'4 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item only) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE 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 4 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)