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IFIED PROGRAM CONSOLIDATED FORK J;� h1I 6-) 1-1/ TANK: TA0505784 /D�/\/�� PR#: P11023156363UNDERGROUND STORAGE TANKS - TANKE�)) ( I FAC#: FA00(I0I t (two pages per tank) TYPE OF ACTIONPage 4 of 7 (Check only item only) ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMITS HANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE >CC ❑ 7 PERMANENTLY CLOSED ON SITE F1 3 RENEWAL PERMIT (Spccifv mason-fon local use only) (Specify reason-for local use onh l ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: J&L MARKET 3 FA0000110 PR0231563 LOCATION WITHIN SITE(Optional) 8115 S EL DORADO ST,FRENCH CAMP PHONE 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 D4 Tank#: 5 43, TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 TA0505784 MODERN WELDING I"Yes",complete one page foreach canpenment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 12,000 ADDITIONAL DESCRIPTION(For local use onh9 438 H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 448 ® 1.MOTOR VEHICLE FUEL ® Ia.REGULAR UNLEADED ❑ 2.LEADED ❑5.JET FUEL (Ifmarkedcomplete Petroleum Type) ❑ 1b.PREMIUM UNLEADED ❑ 3.DIESEL ❑6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ lc.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Imentory page) 441 CAS#(from Hazardous Materials Imentory page) 442 ❑4.HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN HL TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL ❑ 3.SINGLE WALL WITH ❑5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95.UNKNOWN ® 2.DOUBLE WALL ❑4.SINGLE WALL IN VAULT ❑99.OTHER TANK MATERIAL-primary tank ® 1.BARE STEEL p FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 444 (Check one item only) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑99.OTHER TANK MATERIAL-secondary tank ❑ 1.BARE STEEL ❑3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 445 (Check one item only) ❑2.STAINLESS STEEL 4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL --REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING (Check one item only) ❑ 2 ALKYD LINING ❑4 PHENOLIC LINING ❑ 6 UNLINED ® �OTHER BARE STEEL (Fur local use only) OTHER CORROSION ❑ 1 MANUFACTURING CATHODIC ® 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 4t9 PROTECTION IF APPLICABLE PROTECTION (Chock one item only) ❑4 IMPRESSED CURRENT ❑ 99 OTHER ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) 1 SPILL CONTAINMENT 2 L// ❑ 1 ALARM U D FILL TUBE SHUT OFF VAL 2 DROP TUBE ^zC-1VT ❑ 2 BALL ❑4 EXEMPT ❑ 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A description of the matitoring 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 454 ❑ I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one nem only) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑ I VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑7 GROUNDWATER ®2 CONTINUOUS INTERSTITIAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑99 OTHER V.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? 4>7 ❑Yes ❑No UPCF(12/99 revised)