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Mar 19 04 11 : 22a RHL asign Group (925' x13-9709 P. 5 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) P4ge 2 or y TYPE OF ACTION ®I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (U<rk one nem any) ❑ 2 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (speeirymmn-rentreeluseonly) (Spedryeeweon-forlonl usewly) ❑ It TANK REMOVED 430 BUSINESS NAME(SvneanFACIL(TY NAMF.or Dtlp-noing amioess As) FACILITY ID: ' SAFEWAYSTORE!l2707 _ LOCATION WITHIN SITE(optional) 431 6425 PACIFIC AVENUE,STOCKTON,CA L 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 IDN 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 1 MODERN WELDING if.Y._. enmplele one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 4n 2004 20,000 1 ADDITIONAL DESCRIPTION(For twat use omy) 43a IL TANK CONTENTS TANK USE 436 PETROLEUM TYPE 440 19 I. MOTOR VEHICLE FUEL ® la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL prmarkNmmpinepelmlmm Type) [I ib. PREMIUM UNLEADED El 3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED [:14. GASOHOL ❑W.OTHER ❑3. CHEMICAL PRODUCT COMMON NAME(Som H.,doea MateraR tememory page) 441 CAS#(trw r&rdous Materals hmentwy woe) 442 ❑4. HAZAU01JS WASTE oneltadn Uud Oil) REGULAR UNLEADED 8006-61-9 ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OFTANK 01. SINGLE WALL ❑3. SINGLE WALL WITH fl S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (CMckow lmm only) EXTERIOR MEMBRANELINER ❑.95. UNKNOWN N 2. DOABLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-enmoryunk 191. 9;ARESTIEL ❑3. FIBERGLASS 7 PLASTIC El 5. CONCRETE Lj 95. UNKNOWN 444 (CherYone itomonly) [12. STAINLESS STEEL ❑4. STEEL CLAD WIFIBERGLASS [IS. FRP COMPTIBLE W/100%METHANOL [199.OTTIER REINFORCED PLASTIC(FRP) TANK MATERIAL-aworAary took ❑I. BARE STEEL ®3. FIBERGLASS/PLASTIC ❑5. CONCRETE E]95. UNKNOWN 445 (Cheek ow bon only) ❑2. STAINLESS STEEL [14, STEEL CLAD WIFIBERGLASS ❑8. FRP COMPTIBLE W/100%METHANOL O 99.OTHER REINFORCED PLASTIC(FRP) ❑lo.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING I.RUBBER LINED ❑3.EPDXY LINING 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 417 OR COATING ❑2 ALKYD LINING ❑4 PHENOLJC LINING 06UNLINED ❑99 OTHER (Le tam itemonly) (Fwlonitatoonly) OTHER CORROSION ❑I MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN 498 DATE INSTALLED 449 PROTECTION 1F APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OI'HEJ( (cheek we Imm only) ❑2 SACRIFICIAL ANODE (For Iwal me only) SPILL AND OVERFILL YF.ARINSTALLED 4% TYPE(Iwat eta only) a51 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (cheek all that apply) ®1 SPILL CONTAINMENT CNI 2004 420500CL1242368 NI ALARM 2004 ❑3 FILL TUBE SHUT OFF VALVE N 2 DROP TUBE 2004 CNI DTI00 ❑2 BALL FLOAT LJ 4 EXEMPT 03 STRIKER PLATE 2004 Modern Welin IV.TANK LEAK DETECTION(A aeacr;plan onM mm.;mdng prngmm shell he snhm;ned In the meal ag.ney.) IF SINGLE WALL TANK(ckwk all mnaWy) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 (check tam item on)y) ❑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 1714 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENN IAL TANK TESTING ❑990THER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SLIBSTANCE RFMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑ Yes ❑ No UPCF(12/99 revised) to Formerly SWRCB Form B