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7U10 3 r 1FIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Page,,of,- TYPE OF ACTION ❑1 NEW SITE PERMIT ® 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check OOG 11etn 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 FACILITY NAME m DBA-Doing Business As) FACILITY ID: 1 FLAG CITY CHEVRON 3 LOCATION WITHIN SITE(Optional) 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 TANK10 R,0,50,155 70 XERXES lf"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 04(est.)/1995 10,000 ONE ADDITIONAL DESCRIPTION(Fm loa(tueonly) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1.MOTOR VEHICLE FUEL ❑1& REGULAR UNLEADED ❑2. LEADED EIS. JET FUEL (If marked complete Petroleum Type) ❑I b. PREMIUM UNLEADED ®3. DIESEL ❑6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑lc. MIDGRADE UNLEADED ❑4. GASOHOL [199.OTHER [13. CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials inventory page) 441 CAS#(from Hazatdous Materials Inventory page) 442 ❑4. HAZARDOUS WASTE (Includes Used Oil) DIESEL ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK LJ 1.SINGLE WALL El 3. SINGLE WALL WITH Ll 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-Mmary tank U 1.BARE STEEL 3.FIBERGLASS/PLASTIC El 5.CONCRETE 95.UNKNOWN 441 (Check one turn only) ❑2.STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8.FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 1. BARE STEEL 3. FIBERGLASS/PLASTIC 0 5. CONCRETE 95. UNKNOWN 445 (Check one itrn only) ❑2. STAINLESS STEEL 11-14. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5.CONCRETE TANK INTERIOR LINING 1.RUBBER LINED 3.EPDXY LINING El 5.GLASS LINING 95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING (9 6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑I MANUFACTURED CATHODIC KI 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Cheek one iurm 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 all that apply) 911 SPILL CONTAINMENT 2003 ❑1 ALARM ®3 FILL TUBE SHUT OFF VALVE 912 DROP TUBE 2003 ❑2 BALL FLOAT ❑4 EXEMPT 2003 ®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 a0 that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 4w (Check one itup only) ❑1 VISUAL(EJLPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 912 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 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 n/a gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B