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Mar 19 04 11 : 24a RHL =sign Group [9251913-9709 p. 9 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE i (,Rvo pages per tank) Paye 4 of 7 TYPE OF ACTION ®1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANCE OF INFORMATION ❑ 6 1 EMPURARY 5111,CLOSURE (Cheek...hap o.ty) _ ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify ramn-mrl6wl we only) (Sppcfyrmon-forloalwconly) ❑ 8 TANKREMOVED 430 BUSINESS NAME(Same w FACILITY NAME pr DBA-Doing Bwineea As) FACILITY ID: a SAFEWAY STORE#2707 LOCATION WITHIN SITE.(oNknaO 431 6425 PACIFIC AVENUE,STOCKTON,CA 1.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 W 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK N Yes ❑ No 434 2A MODERN WELDING if"Yd.mmplee one page for ane wnpmmmm. DATE INSTALLED(YEAR/MO) 43$ TANK CAPACITY IN GALLONS 426 NUMBER OF COMPARTMENTS 437 2004 1 10,000 2 ADDITIONAL DESCRIPTION(Formal ua only) 452 H.TANK CONTENTS TANK USE 434 PETROLEUM TYPE +40 ®1. MOTOR VEHICLE FUEL ❑la. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (Ifnaulodwmvlua Peuokum Type) ❑lb. PREMIUM UNLEADED ®3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑to. MIDGRADE UNLEADED ❑4. GASOHOL ❑99.OTIIER ❑3. CHEMICAL PRODUCT COMMON NAME (Rom Huardovs Mazeiala lmemory page) MI CASA(fwm H.dous Mamdala Imemory page) 442 ❑4, HAZARDOUS WASTE o.kdw Uaed Oil) DIESEL 8006-61-9 ❑95.UNKNOWN III. TANK CONSTRUCTION TYPEOP TANK ❑I. SINGLE WALL [13 SINGLE WALL WITH [15. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check on dem only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 02. DOUBLE WALL ❑4. SIGNLE WALL IN VAULT [199. OTHER TANK MATERIAL-primary,.A 01. BARE STEEL ❑3. FIBERGLASS/PLASTIC El 5. CONCRETE El 95. UNKNOWN 444 (Check ow he.only) ❑2. STAINLESS STEEL [14. STEEL CLAD W/PIBERGLASS ❑8. FRP COW RBLE W/100%METHANOL [199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-..do,tank L BARE STEEL 03. FIBERGLASS/PLASTIC Ej 5. CONCRETE 095. UNKNOWN 445 (Check one item only) ❑2. STAINLESS S'rEEL ❑4. STEEL CLAD W/FIBERGLASS [39. FRP COMPTIBLE WAOO%METHANOL ❑99.OTHER REINFORCED PLASTIC(PRP) ❑ IO.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING [11.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Cheek oneimm pnly) (Purlecal we only) OTHER CORROSION ❑I MANUFACTURED CATHODIC ®3 FIBERGLASS REINFORCED PLASTIC ❑95 UNKNOWN a48 DATE INSTALLED 444 PROTECTION IF APPLICABLE PROTECTION [14 IMPRESSED CURRENT ❑99 OTHER (Check mm Ikm only) ❑2 SACRIFICIAL ANODE (Por hmat uae only) SPILL AND OVERFILL YEARINSI'ALLED 450 TYPE(locd use ody) 451 OVERFILL PROTECTION EQUIPWNT:YEAR INSTALLED 452 (Checkellthm.PPIO OI SPILT.CONTAINMENT CNI 2004 422100CLI24236B ®1 ALARM 2004 ❑3 FILL TUBE SHUT OFF VALVE ®2 DROP TUBE 2004 CNI DT 100 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE 2004 Modern)Melding IV.TANK LEAK DETECTION(A deaeriplom of the monitoring pmlaam shall he submhtN toga:kcal agenq.) IF SINGLE WALL TANK(chakall thotapply) 453 1F DOUB).E WALL TANK OR TANK WITH BLADDER 454 (Check one nem only) ❑ 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 ®2 CONTINUOUS INTERSTITIAL MONITORING ❑3 CONTINUOUS ATG ❑7 GROUNDWATER ❑3 MANUAL MONITORING Cl 4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING El 99 OTHER IV.TANK CLOSURE INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) ass ESTTMATHD QUANTITY OFSURSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 453 gallons ❑Yes ❑ No UPCF(12/99 revised) 10 Formerly SWRCB Form B