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/ -- IFIED PROGRAM CONSOLIDATED FORMOD ( I I I TANK: TA0505785 X11�� PR#: PRO231563 UNDERGROUND STORAGE TANKS - TANK PA E I Ac#: FA0000l to (two pages per tank) TYPE OF ACTION X Page 6 of 7 (Check onh,item only) ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMIT S CHANGE OF INFORMATION E]6 TEMPORARY SITE CLOSURE ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use odv) I ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: J&L MARKET d FA0000110 PR0231563 LOCATION WITHIN SITE(Optional) 8115 S EL DORADO ST,FRENCH CAMP a; 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 ID# Tank#: 6 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK Yes ❑No 434 TA0505785 MODERN WELDING lf"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 431 6,000 ADDITIONAL DESCRIPTION(For local use only) 439 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® I.MOTOR VEHICLE FUEL If I a.REGULAR UNLEADED ❑2.LEADED ❑ 5.JET FUEL ([fmwkedwmpletePetroleum Type) XIb.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 Invent CAS (from Hazardous Materials[men e ❑4.HAZARDOUS WASTE °7 Page) 441 1O1y ) 4+? (Includes Used Oil) ❑95.UNKNOWN M.TANK CONSTRUCTION TYPE OF TANK ❑ 1.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 ® I.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑95.UNKNOWN 444 (Check one item only) ❑2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑8.FRP COMPTBLE W/1001%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/FBERGLASS ❑ 8.FRP COMPTIBLE W/I00%METHANOL r-PEINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED E] 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 BA OTHER BARE STEEL (For local use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ® 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 449 DATE INSTALLED 4a9 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 0ocal use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply)l SPILL CONTAINMENT I;99"02Ifs, El ALARM )C3 FILL TUBE SHUT OFF VAL' Zoo 2 DROP TUBE Z�� ❑ 2 BALL ❑4 EXEMPT ❑ 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A description of the monitoring 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 item only) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ❑ 1 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? 457 ❑Yes ❑No UPCF(12/99 revised)