COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

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UNIFIED PROGRAM CONSOLIDATED FORM O\ TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (two pages per tank) • Page Z of .PE OF ACTION F 1. NEW SITE PERMIT F 4. AMENDED PERMIT r 5. CHANGE OF INFORMATION) r 6. TEMPORARY SITE CLOSURE Check one item only)F 2. OPERATOR CHANGE �Cy; } r 7. PERMANENTLY CLOSED ON SITE F 3. RENEWAL PERMIT (Specify reason-for local use only) ��" � (Specify change-for local use only) F 8. TANF K REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As)3 FACILITY ID# 1 Country Club Shell LOCATION WITHIN SITE(Opb'ona/)431 2575 Country Club Blvd, Stockton, CA 95204 1.TANK DESCRIPTION A scaled plot plan with the location of the LIST system including buildings and landmarks shall be submitted to the local agency.) TANK ID#7 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK F Yes X No 434 136144-Regular 7,4 0.505&60 Xerxes If AYes_,complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 1995 15,000 ONE ADDITIONAL DESCRIPTION(For local use only) 438 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 X 1. MOTOR VEHICLE FUEL �C ta. REGULAR UNLEADED r 2. LEADED F 5. JET FUEL (if marked,complete Petroleum Type) r tb. PREMIUM UNLEADED r 3. DIESEL r 6. AVIATION FUEL F 2. NON-FUEL PETROLEUM r 1c. MIDGRADE UNLEADED F 4. GASOHOL F 99. OTHER F 3. CHEMICAL PRODUCT F 4. HAZARDOUS WASTE(Includes COMMON NAME(from Hazardous Materials Inventory page)441 CAS#(from Hazardous Materials Inventory page) 442 Used Oil) r 95. UNKNOWN III.TANK CONSTRUCTION YPE OF TANK r 1. SINGLE WALL r 3. SINGLE WALL WITH r 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 ck one item only) X 2. DOUBLE WALL EXTERIOR MEMBRANE LINER F 95. UNKNOWN F 4. SINGLE WALL IN A VAULT F 99. OTHER ANK MATERIAL-primary tank r 1. BARE STEEL X 3. FIBERGLASS/PLASTIC F 5. CONCRETE 1-95. UNKNOWN 444 Check one item only) r 2. STAINLESS STEEL F 4. STEEL CLAD W/FIBERGLASS r 8. FRP COMPATIBLE W/100%METHANOL r 99. OTHER REINFORCED PLASTIC FRP "ANK MATERIAL-secondary r 1. BARE STEEL X 3. FIBERGLASS/PLASTIC r S. FRP COMPATIBLE W/100%METHANOL F 95. UNKNOWN 445 ank F 2 STAINLESS STEEL F 4. STEEL CLAD W/FIBERGLASS r 9. FRP NON-CORRODIBLE JACKET r'99. OTHER Check one item only) REINFORCED PLASTIC(FRP) F 10. COATED STEEL F 5. CONCRETE "ANK INTERIOR LINING F 1. RUBBER LINED r 3. EPDXY LINING F 5. GLASS LINING F95. UNKNOWN446 DATE INSTALLED 447 )R COATING r 2. ALKYD LINING F 4. PHENOLIC LINING X 6. UNLINED F 99. OTHER Check one item only) For local use only) )THER CORROSION r 1. MANUFACTURED X 3. FIBERGLASS REINFORCED PLASTIC r 95. UNKNOWN 448 DATE INSTALLED 449 'ROTECTION IF APPLICABLE CATHODIC PROTECTION r 4. IMPRESSED CURRENT F99. OTHER Check one item only) (For local use only) F 2. SACRIFICIAL ANODE ;PILL AND OVERFILL YEAR INSTALLED TYPE(For local use only)451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 450 Check all that apply) X 1. SPILL CONTAINMENT X 1. ALARM X 3. FILL TUBE SHUT OFF VALVE X 2. DROP TUBE r 2. BALL FLOAT F 4. EXEMPT X 3. STRIKER PLATE IV. TANK LEAK DETECTION (A description of the monitoring program shall be submitted to the local agency.) IF SINGLE WALL TANK(Check all that apply). 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER(Check one item only): 454 F 1, VISUAL(EXPOSED PORTION ONLY) r 5. MANUAL TANK GAUGING(MTG) F 1. VISUAL(SINGLE WALL IN VAULT ONLY) F 2. AUTOMATIC TANK GAUGING(ATG) F 6. VADOSE ZONE X2. CONTINUOUS INTERSTITIAL MONITORING F 3. CONTINUOUS ATG r 7. GROUNDWATER F 3, MANUAL MONITORING r 4. STATISTICAL INVENTORY RECONCILIATION(SIR)r F 8. TANK TESTING BIENNIAL TANK TESTING r 99. OTHER V.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 F Yes F No PCF(1/99 revised) Formerly SWRCB Form B 6