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ED PROGRAM CONSOLIDATED FO jft TANKS 1pJ RGROUND STORAGE TANKS -TANK PAGE i 0 (two pag4l ) Page I of 4 TYPE OF ACTION ®1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT [15 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check one item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify reason-for local use only) (Specify reason-for local use only) ❑ 8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) I 3 FACILITY ID: 0 0 0 0 0 T_IoTo 0 0 0 0 Chevron Station#209167 LOCATION WITHIN SITE(optional) 431 1234 East Yosemite Ave,Manteca CA 95336 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# 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ® No 434 1 XERXES if"Yes",complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 Target 8/1/00 20,000 0 ADDITIONAL DESCRIPTION(For local use only) 438 IL TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 19 1, MOTOR VEHICLE FUEL ®1 a. REGULAR UNLEADED ❑2. LEADED ❑5. JET FUEL (If marked complete Petroleum Type) ❑lb. PREMIUM UNLEADED ❑3. DIESEL ❑6. AVIATION FUEL ❑2. NON-FUEL PETROLEUM ❑ I 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. HA7ARDOUS WASTE (includes Used Oil) REGULAR UNLEADED 800-61-9 ❑95.UNKNOWN III. TANK CONSTRUCTION TYPE OF TANK ❑1. SINGLE WALL ❑3. SINGLE WALL WITH ❑5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 02. DOUBLE WALL ❑4. SINGLE WALL IN VAULT ❑99. OTHER TANK MATERIAL-primary tank ❑ 1. BARE STEEL 03. FIBERGLASS/PLASTIC [15. CONCRETE ❑95. UNKNOWN 444 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank ❑1. BARE.STEEL ®3. FIBERGLASS/PLASTIC ❑5. CONCRETE ❑95. UNKNOWN 445 (Check one item only) ❑2. STAINLESS STEEL ❑4. STEEL CLAD W/FIBERGLASS ❑8. FRP COMPATIBLE W/100%METHANOL ❑99.OTHER REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LINING ❑I.RUBBER LINED ❑3.EPDXY LINING ❑5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD LINING ❑4 PHENOLIC LINING 06UNLINED ❑99 OTHER (Check one item only) (For tical use only) 448 448 OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ID 3 FIBERGLASS REINFORCED PLASTIC El95 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Check one item only) ❑2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED 450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ®1 SPILL CONTAINMENT 2000 ® I ALARM ®3 FILL TUBE SHUTOFF VALVE ®2 DROP TUBE 2000 OPW 61-SO-4 ❑2 BALL FLOAT ❑4 EXEMPT ®3 STRIKER PLATE Tank Mf 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 1F DOUBLE WALL TANK OR TANK W ITI I BLADDER 454 (Check one item only) ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑5 MANUAL TANK GAUGING(MTG) ❑ 1 VISUAL(SINGLE WALT.IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE ®2 CONTINUOUS INTERSTI1 IAL 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 456 TANK FILLED WITH INERT MATERIAE? 457 gallons ❑Yes ❑ No UPCF(1/99 revised) 173 Formerly SWRC13 Form 13