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b. moo I.�-l3�Il UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. Fora UST closureor rem 1,complete only this section andSectlo5 CHANGE OINFORMATION 430. C1I.NEW PERMIT ® 3.RENEWAL PE MIT C] ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE DATE EYISTING UST❑ 8.UST DISCOVERED:REMOVAL 4301,. DATE UST PERMANENTLY CLOSED: I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Some as Facility Name or DBA-Doing Business A Chevron Station#210997 BUSINESS SITE ADDRESS 103. CITY Iw. 1442 A Colony Drive Ripon, CA 95366 II. TAWDESCRIPTION TANK ID# 432 1 TANK MANUFACTIRER 433, TANK CONFIGURATION:THIS TANK IS 434. XEIt E$ N 1.A STAND-ALONE TANK C zn,lcte one page for each 1 ❑ 2.ONE INA COMPARTMENTED UNrr mnpm�^e^t is are mrc. DATE UST SYSTEM INSTALLED +1TANK CAPACITY GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437 01/16/2003 20,0 DO III. TANE USE AND CONTENTS TANK USE ® Ia MOTOR VEHICLE FUELING lb.NU JUNA FUELING 0 1..AVIATION FUELING 439- ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Im3udea Uvea Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§2528L51c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(SpSmfy): 439. CONTENTS PETROLEUM: N la REGULAR UNLEADED ❑ I..MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 140- ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL I 9.OTHER PETROLEUM(Specify): 440' NO N-PETROLEUM: 7.USED OIL 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS ci 4406. IV. TAI K CONSTRUCTION TYPE OF TANK ❑ LSINGLE WALL N 2.DOUBL WALL ❑ 95.UNKNOWN 443' PRIMARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGi ASS [16.INTERNAL BLADDER 444_ ❑ 7.STEEL+INTERNAL LINING_ _ _ 95_UNKNOWN ❑ 99.OTHER(Specify): SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS [16.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. _❑ 90.NONE 0 95.UNKNOWN_ ❑ 99.OTHER(Specify): 445a OVERFILL PREVENTION N L AUDIBLE&VISUAL ALARMS N 2.BALL FLOAT [13.FILL TUBE SHUT-OFF VALVE 452' ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING_CONSTRUCTION ❑ I.SINGLE WALL N 2.DOUBLE WALL-[.] 99.01HER(SpecTy): 460 _ SYSTEM TYPE N 1.PRESSURE ❑ 2.GRAVITY ❑_3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR Q2636(a)p)I 458, PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UN KNp WN _❑ 99.OTHER(Specify): SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBER[LASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b. ❑ 90.NONE ❑ 95.UNK_N 3WN ❑ 99.OTHER(Specify) PIBINGn URBINE CONTAI NMENT SUMP TYPE N I.SINGE W ALL ❑ 2.DOUBLE W ALL ❑ 90.NONE 4644 VI. VENT,VAPOR RECOVERY(VR) kND RISER/FILL PIPE PIPING CONSTRUCTIO N VENT PRIMARY CONTAINMENT ❑ I.STEEL N 4.FIBER SS ❑ 10.RIGID PLASTIC❑ 90.NONE❑ 99.OTHER(Specify): 46,1�1 VENT SECONDARY CONTAINMENT ❑ L STEEL❑ 4.FIBER ASS ❑ 10.RIGID PLASTIC N 90.NONE❑ 99.0THER(Specify): 4648. VR PRIMARY CONTAINMEN T ❑ L STEEL N 4.FIBER S ❑ 10.RIGID PLASTIC❑ 90.NONE❑ 99.OTHER(Specify): M I, VR SECONDARY CONTAINMENT ❑ 1.STEEL❑ 4.FIBERCLASS ❑ 10.RIGIDPLASTIC N 90.NONE❑ 99+OTHER(Specify)_ 4MhL VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLI WALL❑ 2.DOUBLE WALL N 90.NONE 4641. RISER PRIMARY CONTAINMENT N 1.STEEL❑ 4.FIBER LASS ❑ 10.RIGID PLASTIC❑ 90.NONE ❑ 99.OTHER(Specify): 464'3. RISER SECONDARY CONTA INMENT ❑ 1.STEEL❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): 4 kl. FILL COMPONENTS INSTA LLED N 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR N 4.CONTAINMENT SUMP 451ec. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE N 1.SINGLE WALL ❑ 2_DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL. ❑ 1.STEEL N 4.FIB RGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) -4T669 VIII. CORROSION PROTECTION STEEL COMPONENT PROTE CTION ❑ 2.SACRIFICIAL AN DES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION "�. 44a. IX. APPLICANT SIGNATURE �,7t CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information p JAI'dd,R herein is true, accurate,and in full cim Iauce with I al requirements. 470. APPLICANT SIGNATURE: - I DATE 02/11/2011 APPLIC ANI'NAME(Print) Chevron Products Co./ 411' 1 APPLICANT TITLE Chevron RetaiI HES PcOIU42esk an. t UPCF UST-13 Rev.(12/2007)