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IED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) Ngq6-oq TYPE OF ACTION ®I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Chockoneisemonly) 0 ? PERMANENTLY N SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local on only) ❑ 8 TANK REMOVED BUSINESS NAME(Sameaa FACnXrYNAMEor DBA-Doing Busness As) FACILITYID: I` SAFEWAY STORE#2707 LOCATION WITHIN SITE(Options) A4316425 PACIFIC AVE., STOCKTON CAIPI.TANK DESCRTION (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 Ia IA05170(, MODERN WELDING If"Yes',complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 4H',lye 200295 10,000 2 ADDITIONAL DESCRIPTION(For local use only) 3 r•1/� IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ®1. MOTOR VEHICLE FUEL ❑ la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifmarked complete Petroleum Type) ®Ib. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑In. MIDGRADE UNLEADED [14. GASOHOL [199.OTHER [13. CHEMICAL PRODUCT COMMON NAME (from Hazardous Mazerisa Inventory page) 441 CAS#(from Hazardous Materials Inventory page) 442 ❑4, HAZARDOUS WASTE (Ialudea used oil) PREMIUM UNLEADED 8006-61-9 ❑95.UNKNOWN IH. TANK CONSTRUCTION TYPE OF TANK 1. SINGLE WALL ❑3. SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Cheek one barrenly) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN ®2. DOUBLE WALL [14. SIGNLE WALL IN VAULT [199. OTHER TANK MATERIAL-primary suer ®1. BARE STEEL ❑3. FIBERGLASS/PLASTIC 05. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/FIBERGLASS [18 FRP COMPTIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secoMary sand, [11. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑5. CONCRETE [195. UNKNOWN 445 (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 ❑ S. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED [13.EPDXY LINING ❑S.GLASS LINING [195.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Check one it..only) (For las use only) OTHER CORROSION ❑I MANUFACTURED CATHODIC N 3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 44a DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Chock one item only) ❑2 SACRIFICIAL ANODE (For Iacal use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(Iota,use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all as apply) ®1 SPILL CONTAINMENT Phil-Tite SC- 2003 3600-TSC-2-1 ®1 ALARM 2003 ❑3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2003 DPW 61T ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 2003 Modem Welding IV.TANK LEAK DETECTION(A description ofthe monitoring prostate shall be submitted to the lout agency.) IF SINGLE WALL TANK(Chock all that apply) d53 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (Check ane item ody) ❑ I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑I VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 10 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) 453 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 453 gallons [:]Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B