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IED PROGRAM CONSOLIDATED Fole TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 1 (two pages per[ TYPE OF ACTION ®1 NEW SITE PERMIT [14 AMENDED PERMIT [1a n 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE I (Chock one item only) ❑ 7 PERMANENTLY CLOSEDGN SITE ❑ 3 RENEWALPERMIT (Specify reason-forlocal use only) (Specify ransom-for local use only) ❑ 8 TANK REMOVE /p 1310-3 BUSINESS NAME(Same FACILITY NAME or DBA-Doing Boniness An) 3 FACILITY ID: 1 SAFEWAY STORE#2707 LOCATION WITHIN SITE(optional) 6425 PACIFIC AVENUE, STOCKTON,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 N 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ®Yes ❑ No IlAr A70!5 MODERN WELDING If"Yee',wmplete one page for each ocmpartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS a 2 S 3 O y 10,000 2 ADDITIONAL DESCRIPTION(Por meal a,e only) ` IL TANK CONTENTS t y TANK USE 439 PETROLEUM TYPE g`e w ®I. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑S. JET FUEL /\ (Ifmarkei complete Peoolmm Type) ❑Ib. PREMIUM UNLEADED ®3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED [14. GASOHOL [199.OTHER [13. CHEMICAL PRODUCT COMMON NAME (Rom llaz dou,Materials Inventory page) 441 CAS#(from H ard...Material.Inventory page) 442 [14. HAZARDOUS WASTE (Includes Used Oil) DIESEL 8006-61-9 ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL [13. SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Chock one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-prim.ry rank 01. BARE STEEL ❑3. FIBERGLASS/PLASTIC ❑5. CONCRETE 095. UNKNOWN 444 (Check one item only) [12. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑1. BARE STEEL 03. FIBERGLASS/PLASTIC [15. CONCRETE ❑95. UNKNOWN a5 (Check one item only) ❑2. STAINLESS STEEL [:14. STEEL CLAD W/FIBERGLASS [18. FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING [11.RUBBER LINED ❑3.EPDXY LINING [15.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED mil OR COATING ❑2 ALKYD LIFTING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one item only) (For local use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44s DATE INSTALLED 449 PROTECTION I 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 u,e only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ®1 SPILL CONTAINMENT Phil-Tlte SC- 2003 3600-SCA ®I ALARM 2003 ❑3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2003 OP W 61T ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 2003 Modem Welding IV.TANK LEAK DETECTION(A description ofthe monitoring program shall be abmiaed m the local agency) IF SINGLE WALL TANK(Chnak an that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Chock 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 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B