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1 0 0 UNIFIED PROGRAM CONSOLIDATED FORM • TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 1 (two pW per tank) Page 3of 4 TYPE OF ACTION ❑1 KEW SITE PERMIT ❑ 4 AMENDED PERMIT 0 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Cheek one ee.Daly) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Specify mamn-far lord we aaW (Specify myon-lor local meanly) ❑ e TANK REMOVED 430 BUSINESS NAME(Same.pAQl1.[ry NAME or DBA-Dkk,g Bminecr As) 3 FACILITY!D: 0 :.'_J 0000 0 0 0 0 Chevron Station 0209167 LOCATION WITHIN SITE(opdnnal) 431 1234 Yosemite,Manteca CA 95336 1.TANK DESCRII?TION (A scaled plot plan with the locati+m of the UST systsm including buildings and b Mrnarks shall be submitted to the local agency.) TANK ID N d32 TANK MANUFACTURER 4M COMPARTMEN ALIZED TANK Yes No 434 2 XERXES if-Yes".cmn kw an Orta far cub campmtmem. DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 7125/2000 15,000 ADDITIONAL DESCRIPTION(190 k ea w a*) 439 11.TANK CONTENTS TANK USE 439 PETROLEUM TYPE °1O ®1. M07UR VEHICLE FUEL ❑is. REGULAR UNLEADED ❑1 LEADED ❑S. JET FUEL Qf naaked cwipk1e Peaokum Type) N Ib. PREMIUM UNLEADED ❑3.DIESEL ❑0. AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑Ic. MIDGRADE UNLEADED ❑4.GASOHOL ❑99.OTHER_ ❑3.CHEMICAL PRODUCT COMMON NAME(Il m Hazardous MA-daL tarentM 9006) 441 CASt1(Gum Ha mdom Mawriab lnventory pdp) 442 ❑4. HAZARDOUS WASTE (tncraaes Used NO SUPREME UNLEADED 800-61-9 ❑95.UNKNOWN Ill. TANK CONSTRUCTION TYPE OF TANK 0 1. SINGLE WALL 3. SINGLE WALL WITH 0 3. SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check ane item any) EXTERIOR MEMBRANE LINER ❑95. UNKNOWN 19 2. DOUBLE WALL C34. SINGLE WALL IN VAULT ❑99. OTHERTHER TANK MATERIAL-pr ,1. BARE STEEL 3.FIBERGLASS/ S. CONCRETE 95. UNKNOWN 444 iersrytwik (Cl"one iieman(7) ❑Z. STAINLESS STEEL ❑4. STEEL CLAD WIMERGLASS ©& FRP COMPATIBLE W/100%METHANOL (:199.OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-swand,rywa I. BARESTEEL N3. FIBERGLASS/PLASTIC 5. CONCRETE U05. UNKNOWN 447 (Chock ase earn only) ❑2.STAINLESS STEEL ❑4. STEEL CLAD W)FIBERGLASS [IS- FRP COMPATIBLE W"O()%METHANOL ❑99.OTHER REINFORCED PL.AS71C(FRP) ❑10.COATED STEEL ❑5. CONCRETE TANK INTERIOR LIKING 1.RUBBER LINHD 3.&FOXY LINING S.GLASS I ININO 93.UNKNOWN 446 DATE INSTALLED 447 OR COATING ❑2 ALKYD L1NM ❑4 PHENOLIC LINING ®6 UNLINED ❑99 OTHER (Cheri am Imo only) (Ftr kxal eo ooh) Mg 448 OTHER CORROSION 13ED 1 MANUFACTURCATHODIC ®3 FIBERGLASS REINFORCED PLASTIC E395 UNKNOWN PROTECTION IF APPLICABLE PROTECTION ❑4 IMPRESSED CURRENT ❑99 OTHER (Chock one kern only) ❑2 SACRIFICIAL ANODE (F4:loed me ate) SPILL AND OVERFILL YEAR 124STALLED 430 TYPE(wai ase mdy) 431 OVERFILL.PROTECTION EQUIPMENT:YEAR INSTALLED 432 (Chock all that apply) I SPILL CONTA.R�841ENT '] /2 0 3 FILL TUBE SHIT OFF VALVE 19 1 ALARM QPW 61-SO-4 ®2 DROP TUBE 7/2512000 QPW 61-SO-4 ❑2 BALL FLOAT Q 4 EXEMPT ®3 STRIKER PLATE DAM IV.TANK LEAK D+L'TKCTION(A daopian oflbe rooaiarios pwV=shall be rub=W to the krcN agency) IF SINGLE WALL TANK(chat kdithatw*) 4S3 IF DOUBLE WALL TANK OR TANK WITH BLADDER 430 (Cheek am item only) El I VISUAL(EXPOSED PORTION ONLY) 5 MANUAL TANK GAUGING(MTO) ❑!VISUAL(SINGLE WALL IN VAULT ONLY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑6 VADOSE ZONE 2 CONTINUOUS RNTERS77TlAL MONITORING ❑3 CONTINUOUS ATO ❑7 GROUNDWATER ❑3 MANUAL MONITORING ❑4 STATISTICAL INVENTORY RECONCILIATION ❑8 TANK TESTING (SIR) BIENNIAL TANK TESTING Q 99 OTHER IV.TANK CLMRE INFORMATION:PERMAI`4LW CLOSURE hN PLACE ESTIMATED DATE LASTUSED(YR7MOIDAY) 4 5 1 SI7&tATF�QUANTITY OF S(P�'TRNLE REt 1A1t IIIdG 416TA?�K€11.L€1:W]1#!INERT MATERIAL? 457Ballow ®Yes ® No UPCF(1/99 revised) 175 Formerly SWRCB Form B