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0NIFIED PROGRAM CONSOLIDATED FO TANK: TA0508176 wi PR #: PRO231692 N UNDERGROUND STORAGE TANKS - TANK PA61EFAC #: FA0000212 7 y 0'!, (two pages per tank) Page 2 of 7 TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check only Item only) I� ••°I°,i°°''° j� P PBI' j ��I, I ❑ 7 PERMANENTLY CLOSED ON SITE 3 RENEWAL PERMIT ❑ STANK REMOVED 430 BUSINESS NAME (Same as FACB.rrY NAME or DBA - Doing Business As) FACILITY ID: PR #: -M 1 MBP MOSSDALE* 3 FA0000212 PR0231692 LOCATION WITHIN SITE (optional) 444 W MOSSDALE RD, LATHROP 431 PHONE 1. TANK DESCRIPTION (A scaled plot plan with the location of the UST system including and landmarks shall be submitted to the local agency.) TANK ID# Tank #: 4 432 ,buildings - Ig I U �J a33 TAN ff COMPARTMENTALIZED TANK ❑ Yes No 434 ��``��""'''"GGGGGG TA0508176 �.7 p� ° ?1 iLltrCpjtr' If"Yes", complete one page far each compartment. DATE INSTALLED (AR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 % r 10,000 17 ADDITIONAL DESCRIPTION (For local use only) 438 H. TANK CONTENTS TANK USE 439 �P,EETROLEUM TYPE 440 ® 1. MOTOR VEHICLE FUEL YV ta. REGULAR UNLEADED ❑ 2. LEADED ❑ 5. JET FUEL (Ifmarked complete Petroleum Type) lWlb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ 6. AVIATION FUEL ❑ 2. NON -FUEL PETROLEUM ❑ 1 c. MIDGRADE UNLEADED ❑ 4. GASOHOL ❑ 99. OTHER ❑ 3. CHEMICAL PRODUCT COMMON NAME (from Hazardous Materials Inventory page) 441 CAS# (from Hazardous Materials Inventory page) 442 ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 95. UNKNOWN M. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95. UNKNOWN ® 2. DOUBLE WALL ❑ 4. SINGLE WALL IN VAULT ❑ 99. OTHER TANK MATERIAL. - primary tank ® 1. BARE STEEL ❑ FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 444 (Check one item only) ❑ 2. STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8. FRP COMPTIBLE W/ 100% METHANOL REINFORCED PLASTIC (FRP) ❑ 99. OTHER TANK MATERIAL - secondary tank ❑ 1. BARE STEEL ❑ 3. FIBERGLASS / PLASTIC ❑ 5. CONCRETE ❑ 95. UNKNOWN 445 (Check one item only) ❑ 2. STAINLESS STEEL STEEL CLAD W/FIBERGLASS E]8. FRP COMPTIBLE W/100% METHANOL `R. REINFORCED PLASTIC (FRP) ❑ 10. COATED STEEL ❑ 99. OTHER ❑ 5. CONCRETE TANK INTERIOR LINING ❑ 1. RUBBER LINED ❑ 3. EPDXY LINING44" ❑ 5. GLASS LINING ❑ 95. UNKNOWN 446 DATE INSTALLED OR COATING (Check one item only) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING ® 6 UNLINED ❑ 99. OTHER (For local use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ® 3 FIBERGLASS REINFORCED PLASTIC E]95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one item only) ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER ❑ 2 SACRIFICIAL ANODE (Par Local use only) SPILL AND OVERFILL YEEA�ARQINSTALLE45o TYPE (local we only) 451 OVERFILL PROTECTION EQUIPMENT: YEAR INSTALLED 452 1 SPILL CONTAINMENT G _ ` v M' v (Check all that apply) ❑ I ALARM �3 FILL TUBE SHUT OFF VAL` -� 2 DROP TUBE I�rl"2 BALL ��j ❑ 4 EXEMPT 3 STRIKER PLATE 1 FLOAT �-(- IV. TANK LEAK DETECTION (A description of the monitoring program shall be submined to the local agency.) IF SINGLE WALL TANK (Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ I VISUAL (EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING (MTG) (Chat` one item only) ❑ 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE ❑ I VISUAL (SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER ® 2 CONTINUOUS INTERSTITIAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ STANK TESTING ❑ 3 MANUAL MONITORING (SIR) BIENNIAL TANK TESTING ❑ 99 OTHER V. TANK CLOSURE INFORMATION / PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED (YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TAN K FILLED WITH INERT MATERIAL? 457 _1 n/S/IS9$- 0.00 gallons 1:1 Yes ❑ No UPCF (12/99 revised)