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IFIED PROGRAM CONSOLIDATED FOR TANK: TA0515509 PR#: PR0231083 UNDERGROUND STORAGE TANKS - TANK PAGE I �(�JO AC#: FA0003735 (two pages per tank) TYPE OF ACTION Page 4 of 5 (Check only item only ❑ 1 NEW SITE PERMIT [j4 AMENDED PERMIT ❑ 5 CHANG ATION 6 TEMPORARY SITE CLOSURE + c `' * ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT8 TANK REMOVED 430 ❑ BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busincss As) FACILITY ID: PR#: 1 QUICK STOP MART* 3 FA0003735 PR0231083 LOCATION WITHIN SITE(Optional) 2057 S EL DORADO ST,STOCKTON 431 PHONE L 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# Tank#: I 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK V Yes ❑No 434 TA0515509 XERXES If"Yes",complete one page for each compartment DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 '6-�- ✓ ✓ ADDITIONAL DESCRIPTION(For I«at use only) 438 H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® I.MOTOR VEHICLE FUEL AWa.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked complete Petroleum T)pe) [ J gjlb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM , ,❑`Ic.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Im=lm page) ,341 CAS#(frau Hazardous Materials Inventoy page) 442 ❑ 4.HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN Ill.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one itemonly) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ® 2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT ❑ 99.OTHER TANK MATERIAL-primary tank ❑ L BARE STEEL ® FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Check one item only) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/1001/6 METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER TANK MATERIAL-secondary tank ❑ I.BARE STEEL ® 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 (Check one item only) ❑ 2.STAINLESS STEEL ❑4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 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 ❑ 95 UNKNOWN 448 DATE INSTALLED 419 PROTECTION IF APPLICABLE PROTECTION (Check one itemonh) ❑4 IMPRESSED CURRENT ® 99 OTHER ❑ 2 SACRIFICIAL ANODE (Fa local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local useonly) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apph) N I SPILL CONTAINMENT 2,000.00 OPW ❑ I ALARM ® 3 FILL TUBE SHUT OFF VAL` x❑ 2 DROP TUBE 2,000.00 OPW ❑ 2 BALL ❑4 EXEMPT Q 3 STRIKER PLATE 2,000.00 XERXES STEEL FLOAT 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 454 r-1I VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item onh) ❑ 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 ❑ 8 TANK 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 .OFF.SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 "..�----o------�� ❑Yes ❑ No UPCF(12/99 revised)