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IFIED PROGRAM CONSOLIDATED Fow -j T UNDERGROUND STORAGE TANKS TANK PAGE 1 (two ages per ) Page 1 of b TYPE OF ACTION ❑1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ® 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specifymmon-forlocal use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME same,as FACILITY NAME no DBA-Doing Business Aa) 3 FACILITY ID: 0 0 0 0 0 0 0 0 0 0 0 Chevron Station#91452 a LOCATION WITHIN SITE(Optional) Flf-"3 71y 431 334 E Main St.,Ripon,CA 95366 L 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 XERXES If"Yes",complete one page for each compartment. DATE INSTALLED(YEAR(MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 10/1/95 12000 0 ADDITIONAL DESCRIPTION(For local we only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ID 1. MOTOR VEHICLE FUEL Ella. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifmarkdmmplete Petroleum Type) [I 1b. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑10. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materiab Inventory page) 041 CAS#(&rnn Hazardous Materials lnvemory page) aa2 ❑4. HAZARDOUS WASTE (Includes Usad Oil) REGULAR UNLEADED 800-61-9 ❑95.UNKNOWN 111. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER 095. UNKNOWN 02, DOUBLE WALL ❑4. SINGLE WALL IN VAULT ❑99. OTHER_ TANK MATERIAL-primary tank ❑1. BARE STEEL ®3. FIBERGLASS/PLASTIC Cl 5. CONCRETE ❑95. UNKNOWN 444 (Check one demonly) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary mak ❑1. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑5. CONCRETE 095. UNKNOWN 445 (Check one item Doty) [12. STAINLESS STEEL E14. STEEL CLAD W/FIBERGLASS [18. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING [11.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING [195.UNKNOWN 446 DATE INSTALLED 449 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING N 6 UNLINED ❑99 OTHER (Check one item only) (For local we only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 408 448 PROTECTION IF APPLICABLE PROTECTION [14 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local me only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(bml we only) 451OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ®1 SPILL CONTAINMENT ®3 FILL TUBE SHUT OFF VALVE 1995 ®I ALARM OPW 61-SO-4 ®2 DROP TUBE 1998 OPW 61-SO-4 ❑2 BALL FLOAT_ ❑4 EXEMPT ®3 STRIKER PLATE Tank MP _ IV.TANK LEAK DETECTION(A deacription ofthe monitoring pm8r9m shall be mbmitted to the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 050 (Check one dem only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK 6AUGING(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 1 V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST CSED(YR/M04)AY) 466 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 656 TANK FILLED WITH INERT MATERIAL? 417 gallons ❑Yes ❑ No UPCF(1/99 revised) 173 Formerly SWRCB Form B