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-0\ ' D URIFIED PROGRAM CONSOLIDATED FORM -71'alo 3 TANKS UNDERGROUND STORAGE TANKS -TANK PAGE i (two pages per tank) Page-4--of 2- TYPE OF ACTION ❑1 NEW SITE PERMIT ® 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one lean only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILMY NAME or DBA-Doing Business As) FACILITY ID: 1 FLAG CITY CHEVRON 3 LOCATION WITHIN SITE(oprimw) 431 NEAR STREET FRONTAGE-6421 CAPITOL AVE., LODI,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 MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 TANK D55&S XERXES Ir-Yes-,complete we page for eachcomparinem. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 04(est.)/1995 10,000 ONE ADDITIONAL DESCRIPTION(For local use only) 438 U.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL ®la REGULAR UNLEADED ❑2. LEADED [IS. JET FUEL (If marked complete petroleum Type) ❑1 b. PREMIUM UNLEADED [13.DIESEL [16.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑1 c. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME(from Hazardous Mater als Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE (InctudesUsed Oil) REGULAR GASOLINE (87) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK LJ 1.SINGLE WALL Ll 3. SINGLE WALL WITH U 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN IN 2. DOUBLE WALL [14. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank 0 1.BARE STEEL 3.FIBERGLASS/PLASTIC U S.CONCRETE 0 95.UNKNOWN 444 (Check one item only) ❑2.STAINLESS STEEL ❑4. STEEL CLAD WMERGLASS ❑8. FRP COMPTIBLE W/100,/0 METHANOL [:199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 0 1.BARE STEEL 3.FIBERGLASS/PLASTIC 0 5. CONCRETE El 95.UNKNOWN 445 (Check one item only) ❑2.STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100,/o METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 0 1.RUBBER LINED 0 3.EPDXY LINING 5.GLASS LINING C3 95.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 ❑I MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(loaf use may) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Chad[all d-i apply) ®1 SPILL CONTAINMENT 2003 ❑1 ALARM E 3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2003 ❑2 BALL FLOAT ❑4 EXEMPT 2008 ®3 STRIKER PLATE 1995 IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all thatepply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 414 (Check one 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 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 n/a gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Fonnerly SWRCB Fonn B