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Mar 19 04 11 : 23a RHL asign Group (925' 713-9709 p. 7 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two inges per Lard:) Pace of 7 TYPE OF ACTION N I NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 'IEMMRARY SITE CLOSURE (CM1oeknmkemaely) __ ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWALPERMIT (Specify reason-for local 9monly) (Sprrify rows-for tool um only) ❑ 8 TANKREMOVED 410 BUSINESS NAME(Smmas FACILITYNAMEor DOA-D.Ing BusinessM) FACILITYID: I 1 3 SAFEWAY STORE#2707 LOCATION WITHIN SITE into...0 431 6425 PACIFIC AVE., STOCKTON CA L TANK DESCRIPTION (A scaled plot plan with die location of die UST system including buildings Bud landmarks shall be submitted to the local agency.) TANK ID 9 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK N Yes ❑ No 4334 2B MODERN WELDING Ir"Yei.wmplaeomwgefoTaJ MMRmmcue DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 2004 10,000 2 ADDITIONAL DESCRIPTION(For weal no only) 431 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 410 ®1. MOTOR VEHICLE FUEL C3 Is. REGULAR UNLEADED ❑2.LEADED ❑5. JET FUEL (Ifmarkoleomplem Peu4lmmTym) ®Ib. PREMIUM UNLEADED 03. DIESEL ❑6. AVIATION FUEL Cl 2. NON.FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.UI HER ❑3. CHEMICAL PRODUCT COMMON NAME(gom Hansard..Mason.),lnwemnry pa&at 441 CAS#(hom Hasardms Mzhnols l....I.yw,a) 0 4. HAZARDOUS WASTE pookelesumeon) PREMIUM UNLEADED 8006-61-9 ❑95.UNKNOWN ID. TANK CONSTRUCTION TYPE OF TANK ❑I. SINGLE.WALL [13. SINGLE WALL WITH ❑S. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Cheek-bone.only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 02. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank N L BARE STEEL [13. FIBERGLASS/PLASTIC ❑S. CONCRETE, 95. UNKNOWN 444 (uxtonm ilemonly) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8.FRP COWTIBLE W/100%METHANOL ❑W.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-somWar,unk I, BARE STEEL ®3. FIBERGLASS/PLASTIC 0 5. CONCRETE ❑95. UNKNOWN 445 (Check one lmmonly) ❑2. STAINLESS STEEL ❑4. STEEL CLAD WTIBL72GIASS ❑e. FRP COMPTIBLE W/100%METHANOL 099.OTHER REINFORCED PLASTIC(FRP) ❑10.COATED STEEL ❑S. CONCRETE TANK INTERIOR LINING ❑1.RUBBER LINED 0 3.EPDXY LINING ❑S.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED a7 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LMING 0 6 UNLINED ❑99 OTHER (Chep one than only) (For IoW use only) OTHER CORROSION ❑1 MANUFACTURED CATHODIC ®3 FIBERGLASS MNFORCEU PLASTIC ❑95 UNKNOWN 441 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION [14 E-APRESSED CURRENT ❑99 OTHER (Chsk ore ilrnr only) ❑2 SACRIFICIAL ANODE (Forlmel use only) SPILL AND OVERFILL YEARINSTALLED 450 TYPE(lona uEa 9Ny) 451 OVERFILL PROTECTION EQUIPMENT YEAR INSTALLED 452 (Check Nl lhal apply) ®I SPILL CONTAINMENT CNI 2004 420500CL124236B ®I ALARM 2ol4 ❑3 FTLLTUBESHUT.Off VALVE ®2 DROP TUBE 2004 CNI DT 100 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 2004 Modern Welding IV,TANK LEAK DETECTION(A description oftne monuanng wage n shall be whmaid w the Imxl.gemy) IF SINGLE WALL TANK(eneetmlharyaly) 455 IF DOUBLE WALL TANKOR TANK WITH BLADDER 454 (Check ox hem only) ❑I VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC'rANK 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 956 TANK FILLED WITH INERT MATERIAL? 457 gallons ❑Yes ❑ No UPCF(12199 revised) L0 Formerly SWRCB Form B