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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS TANK PAGE 1 (two pages per tank) Page 5 of 6 TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT M 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Chmkoneilemonly) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specifyeason-farlocaluse„only) 8TANKREMOVED 430 BUSINESS NAME($..,FACILITY NAME ur DBA-Doing BusinessAs) 3 FACILITY ID: 0 0 ? 0 0 ' ?'u 0 Chevron Station#91452 LOCATION WITHIN SITE(optional) 431 334 E Main St.,Ripon,CA 95366 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# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 3 XERXES If"Yes",oomplme one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS a36 NUMBER OF COMPARTMENTS 437 10/1/95 12000 0 ADDITIONAL DESCRIPTION(For Inial use only) 438 11.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL ❑N. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) ®lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER_ ❑3. CHEMICAL PRODUCT COMMON NAME (ft.H.dous Maienals Inventory page) MI CAS#(front Haverdous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE (Includes Used Oil) PREMIUM UNLEADED 86290-81-5 ❑95.UNKNOWN 111. TANK CONSTRUCTION TYPE OF TANK [11. SINGLE WALL [13. SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Checkoo<itemanly) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 92. DOUBLE WALL [14. SINGLE WALL IN VAULT [199. OTHER TANKMATEAL-primary lank I. BARE STEEL 3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 4°° RI (Check one rent only) El 2. STAINLESS STEEL El 4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL 099.OTHER_ REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank [11. BARE STEEL ®3. FIBERGLASS/PLASTIC CIS. CONCRETE ❑95. UNKNOWN 445 (Check am item only) ❑2. STAINLESS STEEL [34. STEEL CLAD W/FIBERGLASS [18, FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) [110.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one it..only) (For local use only) OTHER CORROSION ❑I MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 048 448 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check am item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEARINSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ®3 FILL TUBE SHUT OFF VALVE ®1 SPILL CONTAINMENT 2005 5 Gallon Phil-Tite ❑I ALARM OPW 61SO-PT ®2 DROP TUBE 2005 DPW 61 SO-PT ❑2 BALL FLOAT _ ❑4 EXEMPT ®3 STRIKER PLATE Tank Mf _ IV.TANK LEAK DETECTION(A description of monitoring program shall be submitted to the local agency) IF SINGLE WALL TANK(Chink al)that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 45° (Check oro item only) ❑I 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 ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING ❑99 OTHER _ IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 656 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(1/99 revised) 177 ForTnerly SWRCB Form B