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FIED PROGRAM CONSOLIDATED FO UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 7,H,,II/,/V,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 Chevron Station#210997 BUSINESS SITE ADDRESS 103, CITY 104 1442 A Colony Drive Ripon, CA 95366 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 1 XERXES ® 1.A STAND-ALONE TANK Compine one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435- TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 01/16/2003 20,000 0 III. TANK USE AND CONTENTS TANK USE 9 la.MOTOR VEHICLE FUELING ❑ Ib.MARBNA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inllud.s Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252815(1)] ❑ 6.OTHER GENERATOR FUEL [1 95.UNKNOWN _ .❑,99 OTHER(Specify): 439a. .-.. _.__......,_ ........ ...-...-. ._ _. CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc MIDNLE GRADE UADED ❑ Ib PREMNM UNLEADED 440, El El3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑.8.PETROLEUM BLEND FUEL ❑ 9 OTHER-PETROLEUM� cif,). 440a NON-PETROLEUM:❑ 7.USED O - IL ❑ 10 ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION _TYPE OF TANK ❑ 1 SINGLE WALL ® 2 DOUBLE WALL ❑ 95 UNKNOWN 441 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 07.STEEL+INTERNAL LINING [1 95.UNKNOWN [199.OTHER(Specify) 444a DARY SECONCONTAINMENT ❑-1.STEEL ®3.FIBERGLASS ❑ b EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90:-NONE,.,..,.__-.-._❑ 95 UNKNOWN 99 OTHER(Specify): 445a. OVERFILL PREVENTION ® I AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL NBESHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99 OTHER SYSTEM TYPE ® t PRESSURE ❑ 2 GRAVITY ❑ 3 CONVENTIONAL SUCTION ❑ 4 SALE SUCTION[23 CCR§2636(a)(_3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIB-ERGLASS ❑ 8 FLEXIBLE ❑ 10.RIGID PLASTIC 464: ❑.90_NONE ❑ 95.UNKNOWN ❑ 99 OTHER(Specify): 464.. .-.-. _ .._-.... ....._- . _F _...... .-.____... _____.-.-_ ........ . ......... SECONDARY CONTAINMENT ❑ 1.STEEL ® 4 FIBERGLASS ❑ 8 FLEXBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95 UNKNOWN ❑ 99 OTHER(Specify): 464° ..... ___- __. .._..... ........-.. ....... _-'-._.._. ....__,_.------' __-.._.. ......... PIPING/TURBINE CONTAINMENT SUMP TYPE ® I SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® L STEEL [14.FIBERGLASS [1 10.RIGID PLASTIC El 90.NONE [I99.OTHER(Specify): 4°bg64ej VENT SECONDARY CONTAINMENT ❑ I STEEL ❑ 4 FIBERGLASS ❑ 10 RIGIDPLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464H ........_..___. .__ ....-.....-_.._ -__ .._.__ ... VR PRIMARY CONTAINMENT ❑ 1 STEEL ® 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90:,NONE ❑ 99..,OTHER(Specify): qbe ........_.- ._ ... ......---. VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): q4" VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE ..._-...___. ....____.-__.. ___..._-__ .-._........._ _ ._._.... ....__-._. .. ..-.___..__ RISER PRIMARY CONTAINMENT ® I.STEEL ❑ 4 FBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4642. RISER SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE [399.OTHER(Specify): g64k1 _ FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3 STRIKER PLATEMOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451a--., VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 9 1.SINGLE WALL ® 2,DOUBLE WALL 0.3 NO DISPENSERS ❑ 90 NONE 409.. _.. ............._..._..____. ..... - -- - --- -.._EEL-- ......-.-.-- ......-....... ..-.-.-.-__ ------'-'- .-.-.-.-.- CONSTRUCTION MATERIAL ❑ I STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 OTHER(Specify) Obgb' VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION "a. IX. APPLICANT SIGNATURE CERTIFICATION: I cery that tis UST system is compatible with the hazardous substance stored and that the information provided herein is true, accu ie,an till compliance with legal requirements. APPLICANT SIGNATURE: DATE 06/10/2009 °'� APPLICANT NAME(print) Che ron roducts Co./JIM HARTMAN 471. APPLICANT TITLE Retail HES Pelmet Desk 472 UPCF UST-B Rev.(12/2007)