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N IED PROGRAM CONSOLIDATED FOR TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (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 dem only) ❑ 7 PERMANENTLY CLOSED ON SITE ® 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ B TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: 1 3 7-Eleven 32190 LOCATION WITHIN SITE(Optional) 431 4943 S. State Route 99, Stockton, CA 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 MANUFACTURE ` 433 COMPARTMENTALIZED TANK ❑ Yes ® No 434 Yes complete one page for each compartment. DATE INST LLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 438 NUMBER OF COMPARTMENTS 437 15 (o esa ADDITIONAL DESCRIPTION(For local use only) 438 Ih,TANK.CONTENTS TANK USE 430 PETROLEUM TYPE 440 �Y. MOTOR VEHICLE FUEL ❑1a. REGULAR UNLEADED [12. LEADED [15. JET FUEL (If marked complete Petroleum Type) A0 1a. PREMIUM UNLEADED ❑3. DIESEL ❑e. AVIATION FUEL [12. NON-FUEL PETROLEUM [:]lc. MIDGRADE UNLEADED [14. GASOHOL [199.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE ( - (Includes Used Oil) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL L]3 SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one hem only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank 1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑5. CONCRETE El 95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/ ❑99.OTHER REINFORCED PLASTIC(FRP) 100%METHANOL TANK MATERIAL-secondarybmk ❑1. BARE STEEL 03. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE L 199.OTHER 'f REINFORCED PLASTIC(FRP) W1100%METHANOL rrjPk F- A ❑5. CONCRETE [110.COATED STEEL TANK INTERIOR LINING [11.RUBBER LINED [13.EPDXY LINING [15.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 [14 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(localuse only) 451 OVERFILL PROTECTION EOUIPMENT:YEAR INSTALLED 452 (Check ell 1 SPILL CONTAINMENT 1 ALARM ❑3 FILL TUBE SHUT OFF VALVE that apply) }2 DROP TUBE 2 BALL FLOAT ❑4 EXEMPT .3 STRIKER PLATE <IV.TANKLEA -DETECTION(A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Cheek 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 El GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING +(SIR) BIENNIAL TANK TESTING 0 9 OTHER IV'.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/D, 455 ESTIMATED QUANTITY OF SUBSTANCE 456 TANK FILLED WITH INERT MATERIAL? 457 REMAINING gallons ❑Yes ❑ No UPCF (1/99 revised) Formerly SWRCB Form B