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UN,..."00:D PROGRAM CONSOLIDATED F77 'UZ 7 JUN 11 2WNKS UNDERGROUND STORAGE TANKS -TAN AGE 1 ., N e"Ba tank) /�?�/�a Page _ of TYPE OF ACTION Fl. NEW SITE PERMIT r 4. AMENDED PERMIT r 5. CHANGE OF INFORMATION) r 6. TEMPORARY SITE CLOSURE (Check oneltem only)r 2. OPERATOR CHANGE r 7. PERMANENTLY CLOSED ON SITE r3. RENEWAL PERMIT (Specify reason-forlocal use only) (Specify change-forlocal use only) r 8. TANr K REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As)3 FACILITY ID If 1 Ben Holt/ 1-5 Shell, q LOCATION WITHIN SITE(Op6ona/)431 3011 W Benjamin Holt, Stockton, CA 95219 rr / I I.TANK DESCRIPTION (A scaled plot an with the location of Me USTsystem including buikhrigs and landmarks shall be submitted to the local agency.) TANK IDk J 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK r Yes XNo 434 T o5D5 9� 136148-Premium XefXes H Ayes=,complete one page for each compartment. DATE INSTALLED(VEAR(MO) 435 1 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1995 15,000 ONE 114 ADDITIONAL DESCRIPTION(For local use only) 438 I 41� II.TANK CONTENTS TANKUSE 439 PETROLEUM TYPE 440 X 1. MOTOR VEHICLE FUEL r Ia. REGULAR UNLEADED r 2. LEADED r 5. JET FUEL (if marked,complete Petroleum Type) X1b. PREMIUM UNLEADED r 3. DIESEL r 6. AVIATIONFUEL F 2 NON-FUEL PETROLEUM r 1c MIDGRADE UNLEADED r 4. GASOHOL r 99 OTHER F 3 CHEMICAL PRODUCT r 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventory page)441 CAS F(hom Hazardous Materials Inventory page) 442 Used aU F95. UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK r 1. SINGLE WALL r 3. SINGLE WALL WITH r 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one dem only) X2. DOUBLE WALL EXTERIOR MEMBRANE LINER r95. UNKNOWN r 4. SINGLE WALL IN A VAULT F 89. OTHER TANK MATERIAL-primary tank r 1. BARE STEEL X3. FIBERGLASS I PLASTIC r 5. CONCRETE r95. UNKNOWN 444 (Check one item only) r 2. STAINLESS STEEL r 4. STEEL CLAD W/FIBERGLASS r 8. FRP COMPATIBLE W1100%METHANOL r99. OTHER REINFORCED PLASTIC FRP TANK MATERIAL-secondary r 1. BARE STEEL X3. FIBERGLASS I PLASTIC r 8. FRP COMPATIBLE Wll 0 METHANOL r95. UNKNOWN 445 tank F 2. STAINLESS STEEL r 4. STEEL CLAD W/FIBERGLASS r 9. FRP NON-CORRODIBLE JACKET F99 OTHER (Check one item only) REINFORCED PLASTIC(FRP) r 10. COATED STEEL r 5. CONCRETE TANK INTERIOR LINING r 1. RUBBER LINED r 3. EPDXY LINING r 5. GLASS LINING r 95. UNMOWN446 DATE INSTALLED 447 OR COATING F 2. ALKYD LINING r 4 PHENOLIC LINING X 6. UNLINED r 99 OTHER Check one item on For tical use only) OTHER CORROSION r 1. MANUFACTURED X 3. FIBERGLASS REINFORCED PLASTIC r95. UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE CATHODIC PROTECTION r 4. IMPRESSED CURRENT r99 OTHER item (Check orrt only) (For local use only) F 2 SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use orly)451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 450 (Check as that apply) X1 SPILL CONTAINMENT_1995_ X 1. ALARM _1996_X 3. FILL TUBE SHUT OFF VALVE _1995_ X2. DROPTUBE 1995 r 2. BALLFLOAT F4 EXEMPT X3 STRIKERPLATE _1995_ IV. TANK LEAK DETECTION (A description ofthe monsodrg 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(Check one item only): 454 r 1, VISUAL(EXPOSED PORTION ONLY) r 5. MANUAL TANK GAUGING(MTG) r 1 VISUAL(SINGLE WALL IN VAULT ONLY) r2. AUTOMATIC TANK GAUGING(ATG) r6. VADOSEZONE X2. CONTINUOUS INTERSTITIALMONITORING r3. CONTINUOUS ATG r 7. GROUNDWATER r 3. MANUAL MONITORING F 4 STATISTICAL INVENTORY RECONCILIATION(SIR)i r 8 TANK TESTING BIENNIAL TANK TESTING r99, OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRIMO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons r Yes r No 6