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FIED PROGRAM CONSOLIDATED Faw n', UNDERGROUND STORAGE TANK O /u/i6 OPERATING PERMIT APPLICATION- TANK INF ION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 430. ❑ 1.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: 431.. 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ O O 0 _ 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. 7-Eleven# 14117 BUSINESS SITE ADDRESS 103. CITY list. 2725 Country Club Dr Stockton II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. ecny Total Containment 0 L A STAND-ALONE TANK Complete one page for each 0 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. Vt9w ')'30-n'9 10,000 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING 0 Ic.AVIATION FUELING 439. 0 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) 0 5.EMERGENCY GENERATOR FUEL IHSC 4828L5(c)] 0 6.OTHER GENERATOR FUEL 0 95.UNKNOWN ❑ 99.OTHER(Specify). 439a. .--- -_-_.............................._____.-_____-_-_.._..._______-_._-._-..-._.-....__.._________...-_._..-.-_-..--.-.-._-....-._ ------- _ _ CONTENTS PETROLEUM: 0 la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED 0 16.PREMIUM UNLEADED 440 0 3.DIESEL ❑ 5.JET FUEL 0 6.AVIATION GAS 0 S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): ")a. NON PETROLEUM:0 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM Specify): 44nb. IV. TANK CONSTRUCTION TYPE OFTANKD I.SINGLE WALL 0 2.DOUBLE WALL ❑ 95.UNKNOWN 443, PRIv1ARY CONTAINMENT ® L STEEL ----� _ .............--- 0 3.FIBERGLASS 0 6.INTERNAL BLADDER --- - ❑ 7.STEEL+INTERNAL LINING 0 95 UNKNOWN 0 99.OTHER 4441. SECONDARY CONTAINMENT ___-._N ._... ............. ❑ 1.STEEL ❑3.FIBERGLASS ❑ fi.EXTERIOR MEMBRANE LINER ® 7.JACKETED 445. 090.NONE ❑_ 95.UNKNOW N......................❑,99._OTHER(Specify): 4451. OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 0 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0 1.SINGLE WALL 0 2.DOUBLE WALL 0 99.OTHER 46/3. SYSTEM TYPE ® 1 PRESSURE ❑ 2 GRAVITY ❑ 3 CONVENTIONAL SUCTION_ _ ❑ 4 SAFE SUCTION 123_C__CR q_636(a)(3)] 45g __-- _._-_ .......... PRIMARY CONTAINMENT ❑ 1.STEEL 114.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4� 0 90.NONE ❑ 95.UNKNOWN 0 99.OTHER(Specify SECON DARY CONTAWMENT ____ ._-_.---...-._-.....-. ...-.___...._._-_-.-_ ❑ L STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 _ ❑ 90.NONE ❑ 95.UNKNOWN _ .0 99.OTHER(Specify): 4W.PNING/TURBINE CONTAINMENT SUMP TYPE 0 1.SINGLE wALL ❑ 2.DOUBLE WALL 0 90.NONE 1641. VI. VENT,VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 4�e' ............. ...... ..__..-.-.___ .-.-.-. -. 4(1 L_ VENT SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 464f' _.... _______ _________..------------------------_....._ ___.-___ --........-_.-- ____..____ _46,10.- VR PRIMARY CONTAINMENT 0 1 STEEL 19 4 FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 4Mg' _.._ __ ........ . .. ......._. ....._......... ... ..____.-.. __._.......... -.-.-_-._ ---'-__. 4fi4g1. VR SECONDARY CONTAINMENT 0 I STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): a6ah,. ............_. ____ ... ............_ VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL 0 2.DOUBLE WALL 0 90.NONE _._ _------.... ... ........... .._.._ ................ .._............ ____.-.- .................... .......-._. ---------------..---...-' _---.__...__ RISER PRIMARY CONTAINMENT 0 1 STEEL 0 4 FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): j. . ._...._-..____ ................ -..._...__.. .__ .-.-....-...-.. ..-.-..___ _.._-__.-_ .. ..........................._...___. .-4-._1-._.. RISER SECONDARY CONTAINMENT ❑ I STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 44644ki. FILL COMPONENTS INSTALLED 0 1 SPILL BUCKET 0 3 STRIKER PLATEIBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45fe c: VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1 SINGLE WALL 0 2.DOUBLE WALL 0 3,NO DISPENSERS 0 90.NONE 4(19a. N .._ -_.--.___ ._.._____ ------ .___--_ __..._.... ..._._.-_.-_... .-______ CONSTRUCTION MATERIAL ❑ 1 STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 OTIiER(Specify) 469b. 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODES) 0 4.IMPRESSED CURRENT 0 6.ISOLATION 448 IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATEL A, /e 470. i APPLICANT NAME(print) Ian Moorhead 471. APPLICANT TITLE Env. Compliance Mgr. 472. UPCF UST-B Rev.(1212007)-1/2 www.unidoes.org