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r bw"- d\ � �1a�63 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Page-I-of 2-- TYPE OF ACTION ❑I 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 meson-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: 1 FLAG CITY CHEVRON 3 LOCATION WITHIN SITE(options) 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 I S', 0If XE RXES If"Yes",complete one page for each compamnenL 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 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL ®I a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked romplem Petroleum Type) ❑1 b. PREMIUM UNLEADED ❑3.DIESEL ❑6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑10. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTHER ❑3.CHEMICAL PRODUCT COMMON NAME(Som Hazardom Materials Inventory page) 441 CAS#(from Hazardous MeteriaLs Inventory page) 442 ❑4. HAZARDOUS WASTE (Includes Used O)I) REGULAR GASOLINE (87) ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK U 1.SINGLE WALL 0 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 ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank LI 1.BARE STEEL 99 3. FIBERGLASS/PLASTIC 0 5.CONCRETE U 95.UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTEBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1.BARE STEEL 3. FIBERGLASS/PLASTIC 5. CONCRETE U 95.UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WNIBERGLASS [18. FRP COMPTIBLE W/100 METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING 5.GLASS LINING 0 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING IN 6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC E 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(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check a0 that apply) ®I SPILL CONTAINMENT 2003 ❑1 ALARM E 3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2003 ❑2 BALL FLOAT ❑4 EXEMPT 2003 913 STRIKER PLATE 1995 IV.TANK LEAK DETECTION(A descripuon of the monitoring program shall be submitted w the local agency.) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 4 w (Check one item only) ❑1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATO) ❑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 FILLED WITH INERT MATERIAL? 457 ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK n/a gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B