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IED PROGRAM CONSOLIDATED F019 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 I,II,I/I,IV,and M below) 430. ❑ L NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1' 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 953660 H. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 2 XERXES ® 1.A STAND-ALONE TANK Complete one page foresch ❑ 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 43z 01/16/2003 15,000 0 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ In MARINA FUELING ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] _ El 6_OTHER GENERATOR FUEL_______............_0._95.UNKNOWN..._..............._.._____..___...._....____._0_99:_OTHER(Specify). 4394. CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ® Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8:_PETROLEUM BLEND FUEL.............❑ 9 OTHER PETROL.RM Specifp): 440 NON-PETROLEUM:❑ 7.USED OIL ❑ IO.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 44ob. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN443. PRIMARY CONTAINMENT [II.STEEL ® 3.FIBERGLASS El -6.INTERNAL BLADDER 444. ❑ 7..STEEL+INTERNAL LINING El 95.UNKNOWN 0 99..OTHER(Specify): 444, AS ..-_ SECONDARY CONTAINMENT ❑ 1.STEEL ®3 FIBERGLS [i6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. ...............................'__-.........._._..........__.....__..__..__............................-.........__..__.____..........._.._....__._.__.___._. .-............--....-..._.. OVERFILL PREVENTION ® I.AUD®LE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-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 460. ____ _..-.._-__. . ..___ ..3 ....... .. SYSTEM TYPE ® 1 PRESSURE__,_❑ 2.GRAVITY ❑ 3 CONVEMIONAL SUCTION ❑ 4 SAFE SUCTION(23¢¢R§2636()(3)] 4se_ PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464_ ❑ 90.NONE ❑ 95 UNKNOWN ❑ 99 OTHER(Specify): 4644. SECONDARY CONTAINMENT ❑ 1.STEEL ® 4 FIBERGLASS ❑ 8 FLEXIBLE ❑ I0.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464.. .__ .. .......... .... ..._.......- ....____.-At- t _....... ____.. . _............. PIPING/TURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q4"c _..____-- _.-.__. ........__..... ._.____ ...-..-......_. ....._____.._ _464f VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4648 ....... _________. ....- .... .___.._.. ._-,.__.-----------------_ ....__.. .___.___ ................ ate.... VR PRIMARY CONTAINMENT ❑ 1 STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 469 e ._....... .._____ ----------------- .._____. ............. -_........ .......................--. 46t1i... VR SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4 FIBERGLASS ❑ I0.RIGIDPLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 46gh1 VENT PIPING TRANSITION SUMP TYPE ❑ 1 SINGLE WALL ❑ 2 DOUBLE WALL ® 90.NONE 4641 _.-................... _..______ .................... ....._.__. ........._..__...--464y RISER PRIMARY CONTAINMENT ® I STEEL ❑ 4 FIBERGLASS ❑ ]0.RIGID PLASTIC [1 90.NONE 99.OTHER(Specify) 464jt, RISER SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4.FIBERGLASS El 10.RIGID PLASTIC ® 90.NONE [399.OTFER(Specify): 464k FILL COMPONENTS INSTALLED ® 1 SPILL BUCKET ® i STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMEM$UMP 4514-c:"" VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2 DOUBLE WALL ❑ 3 NO DISPENSERS ❑ 90 NONE 469.. ...... ........... ._._. .._.. ___.. ... ....._._. ............__ ................ ___........... _._..__ ........... 111-- ._...... _. ..... CONSTRUCTION MATERIAL ❑ 1 STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99 OTHER(Specify) 4696' VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449 IX APPLICANT SIGNATURE CERTIFICATION4C , UST system is compatible with the hazardous substance stored and that the information provided herein is true, com liance with le al re uirements. 70 APPLICANT SIGNDATE 06/10/2009 472 APPLICANT NAModucts Co./JIM HARTMAN 471. APPLICANT TITLE Retail HES Permit Desk 472 UPCF UST-B Rev.(12/2007)