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2004 10:23 2099310560 CAETROil 1580 <br />'qVIIFIED PROGRAM CONSOLIDATED <br />TYPE OF ACT TE PERMIT ION 0 1 NEW SI MT1 0 4 AMEN )FT) lWYMIT 0 S CHAIN06 OF INFORMATION El 6 TEMPORARY SITE CLOSURE <br />PAGE 02/05 <br />TANKS <br />(t-0 Pagc5 per tank) <br />11 <br />page I Of I <br />(Check one idem only)❑7 PERMANENTLY CLOSED ON 5 rrE <br />3 RENEWAL PERMIT- (Spccif.y reason - for toctil use only) STANK REMOVED 47 0 <br />]BU$FNE5S NAME (Same as FACILITY NAME ., DBA - Doing Business AN) <br />Chevron Station 999840 <br />FACILITY ID; <br />0 <br />LOCATION WITHIN SITE (Optional) <br />451 <br />1. TANK DESCRIPTION (A scaled Plot plan With the location of the UST system including buildings and landmarks shall be submitted to the local agency.) <br />TANK ID if 432 <br />TANK MANUFACTURER 4J.3 <br />COMPARTMENTALIZED TANK [-7-Ye-s'0 -No 434 <br />1 <br />XERXES <br />tf"Ya5", complete one page for each compartment. <br />-NUMBER OF COMP-'­ <br />APTMCNTS 437 <br />L)A:I*E INSTALLED (YEAR/Mo) 435 <br />TANK CAPACITY IN GALLONS Zo <br />3/12/98 <br />20,000 <br />0 <br />ADDITIONAL, DESCRIPTION (For local useonly) 438 <br />4344 Waterloo Road, Stockton CA 95215 <br />11. TANK CONTENTS <br />TANK USE 439 <br />PETROLLUMTYFE 440 <br />1. MOTOR VEHICLE FUEL <br />);i, REGULAR UNLEADED D 2. LEADED 115, JET FUEL <br />(Ifmarked completc Petroleum Type) <br />1 b. PREMIUM UNLEADED ❑ 3, DIESEL 0 6. AVIATION FUEL <br />❑ 2. NON -FUEL PETROLEUM <br />0 1c. MIDGRADE UNLEADED ❑ 4. GASOHOL 1199. OT MR <br />❑ 3. CHEMICAL PRODUCT <br />COMMON NAME (from livat-ftue Materials Inventory page) 441 <br />CAS# (from F(martiqu, Materials ln�t;Rtqry page) 442 <br />04. HAZARDOUS WASTE <br />(h'ovdt' lined Oil) <br />REGULAR UNLEADED <br />800-61-9 <br />❑ 9$. UNKNOWN <br />I <br />111. TANK CONSTRUCTION <br />TYPE. Of TANK Ml SINGLE WALL [13, SINGLE WALL WITH El 5. SINGLE WALL WITH INTIERNA1, BLADDER SYSTEM 443 <br />(Check one item qnl,v) EXTERIOR MEMBRANE LINER 0 95. UNKNOWN <br />02. DOUBLE WALL 134. SINGLE. WALL IN VAULT C1 99. OTHER <br />TANK MATERIAL, primary tank L1 1, BARE STEEI, 01, FIBERGLASS I PLASTIC 5.CONCRETE, 0 95. UNKNOWN 444 <br />(Ch -k 6.e itu only) STAINLESS STEEL 0 4. S*FEFIL CLAD W/rIDERGLASS E] 8, IRP COMPATIDLL W/100% MrTIIANOL OTHER <br />REINFORCED PLASTIC (FRP) <br />TANK MATERIAL, secondary tank U 1. BARE STEEL 0 3. FIBERGLASS 7-PL`ASfiC El 5.CONCRETE 95. UNKNOWN 445 <br />(Check one Item on1j) t3 2. STAINLESS STEEL []4. STEEL CLAD WfFIDERGLASS El &. P" COMPATIBLEW/100% METHANOL 0 99, OTHER <br />REINFORCED PLASTIC (FRP) 0 10, COATED STEEL <br />El 5. CONCRETE <br />TANK INTERIOR LINING [11. RUBBER LINED 3. EPDXY LINING 0 5. GLASS LINING 95. UNKNOWN 446 DATE INSTALLED 447 <br />OR COATING 0 2 ALKYD LINING El 4 PHENOLIC LINING 0 6 UNLINED 0 99 OTWR <br />(cheek one 4M only) (Fop local use only) <br />OTHER CORROSION El I MANUFACTURED CATHODIC 10 3 FIBERGLASS REINFORCED PLASTIC El 95 UNKNOWN <br />PROTECTION IF APPLICABLE PROTECTION ❑ 4 IMPRESSED CURRENT El 99 OTHER <br />(Chock one item only) ❑ 2 SACRIFICIAL ANODE (For lQcjl viie only) <br />SPILL AND OVERFILL YEAR INSTALLED 450 TYPE (I"ol use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALL ED 452 <br />(Chrck all that appl-v) 0 1 SPILL CONTAINMENT 1998 R 3 FILL TUBE SI IUTOFF VALVE <br />0 1 QE -w -CL -1Q -i <br />02DROP TIJ)3E R919 OP 0 2 BALL FLOAT- 0 2 BALL FLOAT <br />0 3 STRIKER PLATE ---LLT Tank Tank <br />IV- TANK LEAK DETECTION (A description of the monitoring RM@TZM 5hRli be Submitted to the local agency.) <br />If SINGLE WALL TANK thm opply) <br />Ir DOUBLE WALL TANK OR TANK WITH BLADDER nsa <br />((',heck one item only) <br />0 J VISUAL (EXPOSIT) PORTION ONLY) 5 MANUAL TANK GAUGING (MTG) <br />0 1 VISUAL (SINQLF. WALL IN VAULT ONLY) <br />0 2 AUTOMATIC TANK GAUGING (ATG) ❑ 6 VADOSE ZONE <br />2 2 CONTINUOUS INTEASTN IAL MONITORING <br />03 CONTINUOUS ATG El 7 GROUNDWATER <br />0.3 MANUAL MONITORING <br />0 4 STATISTICAL INVENTORY RECONCILIATION El 8 TANK TEITINC; <br />jSIR) BIENNIAL TANK TESTING El 99 OTHER - I <br />IV. TANK CLOSURE INFORMATION J PERMANENTCLOSURE IN PLACE <br />ESTIMATED DATE LAST USED (YR/MQ/DAY) 455 <br />ESTIMATED QUANTITY OF SUBSTANCE REMAINING 45' <br />'ANK FILLED WITtl INERT MATERIAL? <br />Bailors <br />UPCF' W99 reviscd173 Forrneriv SWRC.B Form B <br />