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REQ IV D UNIFIED PROGRAM CONSOLIDATED FO JUN 117UB ;ZIa2 �� UNDERGROUND STORAGE TANKS -TANK PAGEWI OFFF� Page of TYPE OF ACTION IF 1. NEW SITE PERMIT F 4. AMENDED PERMIT F 5. CHANGE OF INFORMATION) F 6. TEMPORARY SITE CLOSURE (Check one item only)F 2. OPERATOR CHANGE F 7. PERMANENTLY CLOSED ON SITE T3. RENEWAL PERMIT (Speclry,reason-for local use only) (Speaty charge-for local use only) F 8. TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As)3 FACILITY ID# 1 Ben Holt/1-5 Shell LOCATION WITHIN SITE(Opliona/)431 3011 W Benjamin Holt, Stockton, CA 95219 I.TANK DESCRIPTION (A scaled lotp/an with the location ofthe UST system induct buildngs and landmarks shall be submitted to the local agency.) TANK ID#n 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK I Yes E No 434 136146-WASTE OIL OWENS CORNING IfAYes=_,complete one page for each compartmen DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1987 550 ONE ADDITIONAL DESCRIPTION(Fo Iocal use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 T 1. MOTOR VEHICLE FUEL r la. REGULAR UNLEADED r 2. LEADED I� 5. JET FUEL (if marked complete Petroleum Type) F 16. PREMIUM UNLEADED r 3. DIESEL I 6. AVIATION FUEL C 2. NON-FUEL PETROLEUM F 1c. MIDGRADE UNLEADED F 4. GASOHOL I 99. OTHER F 3. CHEMICAL PRODUCT X4, HAZARDOUS WASTE(Includes COMMON NAME(firm Hazardous Materials Inventory page)441 CAS#(fiom Hazardous Materials hrventorypege) 442 Used Dip USED OIL ro. UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK r 1. SINGLE WALL F 3, SINGLE WALL WITH r 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) X2. DOUBLE WALL EXTERIOR MEMBRANE LINER F95. UNKNOWN r 4. SINGLE WALL IN A VAULT F 99. OTHER TANK MATERIAL-prenary tank r 1. BARE STEEL X3. FIBERGLASS/PLASTIC r 5. CONCRETE F95. UNKNOWN 444 (Check one item only) I' 2, STAINLESS STEEL F4. STEEL CLAD W/FIBERGLASS I 8. FRP COMPATIBLE W/1 Do%METHANOL F99. OTHER REINFORCED PLASTIC FRP TANK MATERIAL-secondary F 1. BARE STEEL X3. FIBERGLASS/PLASTIC I 8. FRP COMPATIBLE W1100%METHANOL F95. UNKNOWN 445 tank F 2, STAINLESS STEEL I' 4. STEEL CLAD W/FIBERGLASS r 9. FRP NON-CORRODIBLE JACKET F 99. OTHER (Check one item only) REINFORCED PLASTIC(FRP) rto. COATED STEEL F 5. CONCRETE TANK INTERIOR LINING F 1. RUBBER LINED F 3. EPDXY LINING F 5. GLASS LINING F 95. UNKNOWN446 DATE INSTALLED 447 OR COATING 12. ALKYD LINING I 4, PHENOLIC LINING X6. UNLINED 199. OTHER Check one dem only) (For local use only) OTHER CORROSION r 1. MANUFACTURED X3, FIBERGLASS REINFORCED PLASTIC F95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE CATHODIC I 4. IMPRESSED CURRENT I99. OTHER PROTECTION (Check one item only) (For tical use only) F 2 SACRIFICIAL ANODE SPILL AND OVERFILL YEAR INSTALLED TYPE(For local use only)451 OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED 452 450 (Check all that apply) X 1. SPILL CONTAINMENT_1996_ F 1. ALARM F 3. FILL TUBE SHUT OFF VALVE I' 2. DROPTUBE X 2. BALL FLOAT_1987_ F 4. EXEMPT X 3. STRIKER PLATE _1987_ IV. TANK LEAK DETECTION (A description of the monitoring program shall be submittedto the local agency) IF SINGLE WALL TANK(Check all that apply): 453 IF DOUBLE WALL TANK OR TANK WITH 13LADDER(Check one item only) 454 11, VISUAL(EXPOSED PORTION ONLY) 15 MANUAL TANK GAUGING(MTG) F 1. VISUAL(SINGLE WALL IN VAULT ONLY) I 2. AUTOMATIC TANK GAUGING(ATG) F6. VADOSEZONE X2. CONTINUOUS INTERSTITIAL MONITORING 13. CONTINUOUS ATG F 7 GROUNDWATER F 3. MANUAL MONITORING I 4 STATISTICAL INVENTORY RECONCILIATION(SIR)+ F 8 TANKTESTING BIENNIAL TANK TESTING F99, OTHER V.TANK CLOSURE INFORMATION I PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YRIMOIDAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 4% TANK FILLED WITH INERT MATERIAL? 457 gallons FYes FNo 7