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r IFIED PROGRAM CONSOLIDATED FO TANK: TA050791s PR#: PR0232418 UNDERGROUND STORAGE TANKS -TANK PAGE 1 FAC#: FA0004064 (two pages per tank) Page 6 of 7 TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check only item only) (w r.¢;�,f,} r< ; ;y'i w"1''��"� w�1� � �� I $ � '�''� ❑ 7 PERMANENTLY CLOSED ON SITE ❑3 RENEWAL PERMIT '' ❑ 8 TANK REMOVED 430 BUSINESS NAME(Sart:as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: 1 WATERLOO LIQUOR 3 FA0004064 PR0232418 LOCATION WITHIN SITE(Optional) 2512 E WATERLOO RD,STOCKTON 431 PHONE I.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#: 6 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 TA0507918 MODERN If"Yes",complete one page for each corrpanment DATE INSTALLED(YEAR/MO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 4,000 ADDITIONAL DESCRIPTION(For local use only) 438 H.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ❑ 1 a.REGULAR UNLEADED ❑2.LEADED ❑ 5.JET FUEL (If marked complete PetmleumType) ® Ib.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 Invent CAS# limn Hazardous Materials Invent page) ❑ 4.HAZARDOUS WASTE ( Inventory 441 ( °is p g) 442 (h:ludes Used Oil) ❑ 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 ® 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 wily) ❑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 ❑ 1 MANUFACTURING CATHODIC ® 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one itemcory,) ❑ 4 IMPRESSED CURRENT El 99 OTHER ❑ 2 SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ❑ 1 SPILL CONTAINMENT 1,998.00 ❑ I ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2DROP TUBE ❑ 2BALL ❑ 4EXEMPT ❑ 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A description o£the monitoring program shall be subrrutted to the local agency) IF SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 454 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one mem ottlY) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ 1 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 OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 9/11/1998 0.00 gallons ❑Yes ® No UPCF(12/99 revised)