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IFIED PROGRAM CONSOLIDATED FO14FRTANK: TA0507917 PR#: PRO232418 UNDERGROUND STORAGE TANKS -TANK PAGE 1 FAC#: FA0004064 (two pages per tank) TYPE OF ACTION ❑ I NEW SITE PERMIT ❑4 AMENDED PERMIT ❑ 5 CHANGE OF INFORMATIONPage 4 of 7 ❑ 6 TEMPORARY SITE CLOSURE (Check only item only) OEM vaiiir, ❑ 7 PERMANENTLY CLOSED ON SITE ❑3 RENEWAL PERMIT ❑MIMENNINI 8 TANK REMOVED 430 BUSINESS NAME(Satre as FACILrrY NAME a DBA-Doing Business As) FACILITY ID: PR#: I WATERLOO LIQUOR 3 FA0004064 PR0232418 LOCATION WITHIN SITE(Optional) 2512 E WATERLOO RD,STOCKTON 431 PHONE 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# Tank#: 5 432 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑Yes ❑No 434 TA0507917 MODERN If"Yes",enn4lete ate page for each conpamnent. DATE INSTALLED(YEAWMO) 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS 437 8,000 ADDITIONAL DESCRIPTION(Fork cal use only) 438 U.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ❑ 1 a.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked wnylete Petroleum Type) ❑ I b.PREMIUM UNLEADED ® 3.DIESEL ❑ 6.AVIATION FUEL ❑2.NON-FUEL PETROLEUM ❑ lc.MIDGRADE UNLEADED ❑4.GASOHOL ❑ 99.OTHER ❑3.CHEMICAL PRODUCT COMMON NAME(frmn Hazardous Materials hwen CAS# from Hazardous Materials Invent unyPage) 441 ( ay Page) aaz ❑4.HAZARDOUS WASTE (Includes Used Oil) ❑ 95.UNKNOWN M.TANK CONSTRUCTION TYPE OF TANK ❑ L 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 nematly) ❑ 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 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 (Fa local use only) OTHER CORROSION ❑ I MANUFACTURING CATHODIC ® 3 FIBERGLASS REINFORCED PLASTIC ❑ 95 UNKNOWN 448 DATE INSTALLED 449 PROTECTION IF APPLICABLE PROTECTION (Check one itan only) ❑ 4 IMPRESSED CURRENT ❑ 99 OTHER ❑2 SACRIFICIAL ANODE (Fm local use arty) SPILL AND OVERFILL YEAR INSTALLE450 TYPE(local use only) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ❑ I SPILL CONTAINMENT 1,998.001 ALARM ❑ 2 DROP TUBE ❑ ❑ 3 FILL TUBE SHUT OFF VALE ❑ 2 BALL ❑ 4 EXEMPT ❑ 3 STRIKER PLATE 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 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Cts ate item only) ❑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 1 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 9/11/1998 0.00 gallons ❑Yes ®No UPCF(12/99 revised)