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10 IED PROGRAM CONSOLIDATED FOR TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per tank) Paga_of TYPE OFACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check Ona item only) ❑ 7 PERMANENTLY CLOSED ON SITE ® 3 RENEWAL PERMIT (Specify reason-for local use only) (Speciy,reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID: 1 7-Eleven 32190 LOCATION WITHIN SITE(Optional) 431 4943 S. State Route 99, Stockton, CA 1.TANK DESCRIPTION (A scaled plot plan;with the location of the UST system including buildings and landmarksshall be submitted to the local agency.) TANK ID# .�� 432 TANK UFACTURE/R y `1433 COMPARTMENTALIZED TANK ❑ Yes ® No 4a4 a t✓ (,)ITT { '1�(t`ok If"Yes',complete one page for each compartment DATE IryST LLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 (e � ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 '91. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2 LEADED []5. JET FUEL (If marked complete Petroleum Type) [:I 1b. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM 91c. MIDGRADE UNLEADED [14. GASOHOL [199.OTHER_ ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 [14. HAZARDOUS WASTE (Includes Used oil) / � Y-� ❑95.UNKNOWN (J 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) �Qy[ EXTERIOR MEMBRANE LINER El 95. UNKNOWN -2. DOUBLE WALL []4. SIGNLE WALL IN VAULT [199. OTHER TANKMATERIAL-primarytank 1. BARE STEEL [13. FIBERGLASS/PLASTIC 05. CONCRETE [195, UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE W/ [199.OTHER REINFORCED PLASTIC(FRP) 100%METHANOL TANK MATERIAL-secondarytank []1. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE [195. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE 499.OTHER , 'f' ` REINFORCED PLASTIC(FRP) W/100%METHANOL r h";/ /;„/ ❑5. CONCRETE ❑10.COATED STEEL TANK INTERIOR LINING [11.RUBBER LINED ❑3.EPDXY LINING ❑S.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2ALKYD LINING ❑4 PHENOLIC LINING ❑6 UNLINED ❑99 OTHER (Check one Rem only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC❑3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION [14 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 457 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all Id1 SPILL CONTAINMENTI q 471 ALARM ❑3 FILL TUBE SHUT OFF VALVE that apply) 77� ( fT 2 DROP TUBE 2 BALL FLOAT ❑4 EXEMPT 3 STRIKER PLATE 4V- IV.TANK LEAK DETECTION(A description of the monitoring Program shall be submitted toihe local agency.) IF SINGLE WALL TANK(Checker 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(MITE) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 2 CONTINUOUS INTERSTITIAL MONITORING [:13 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION -10 TANK TESTING +(SIR) BIENNIAL TANK TESTING IT 99 OTHER IV.TANK CLOSURE INFORMATION I.PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE 456 TANK FILLED WITH INERT MATERIAL? 451 REMAINING gallons ❑Yes ❑ No UPCF(1/99 revised) Formerly SWRCB Form B