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FIED PROGRAM CONSOLIDATED FOW &17-1 UNDERGROUND STORAGE TANK (o� OPERATING PERMIT APPLICATION-TANK INF ION (One forth 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: 430.. 1 DATE EXISTING UST DISCOVERED: 4301,. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ O p O _ 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. 7-Eleven# 14117 BUSINESS SITE ADDRESS 103. CITY IN. 2725 Country Club Dr Stockton II. TANK DESCRIPTION TANK ID# -7613 8.7 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. Total Containment 0 I.ASTAND-ALONE TANK Complete one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT companmem at the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY W GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 432 4tt9% 1.30.0Iwt 10,000 III. TANK USE AND CONTENTS TANK USE 0 Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ It.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.IIAZARDOUS WASTE(Includes Used oil ❑ 5.EMERGENCY GENERATOR FUEL IHSC,25281.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. _......._ ----HATH ...._..... ........-_.-.. -.-__'_--_-_-_ CONTENTS__ PETROLEUM: ❑ I.,REGULAR UNLEADED ❑ Ic MIDGRADE UNLEADED ® lb PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): "os._... _.__._._..._ -_.-.L -.__.-- -.-.-.-..._ ............... ._._.. NON PETROLEUM ❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4'101. IV. TANK CONSTRUCTION _TYPE OF TANK ❑ I.SINGLE WALL_ ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. _ PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.Fl _____❑ BERGLASS W.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 44aa. ._- . .. .. .. -0--i-STEEL -.... . . ...............-' __"__- _ ___ _-. SECONDARY CONTAINMENT ❑ L STEEL [13.FIBERGLASS ❑ 6 EXTERIOR MEMBRANE LINER R 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445x. OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 0 3.FILL TUBE SHUT-OFF VALVE 45+_- ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ L SINGLE WALL 0 2.DOUBLE WALL ❑ 99.OTHER SYSTEM TYPE _ __ ® 1.PRESSURE ❑ 2 GRAVITY E-1-3.-CONVENTIONAL SUCTION [I4.SAFE SUCTION R3 CCR 6'-fi36 a)(sl 458. _.____ PRIMARYCONTAINMENT ❑ L STEEL 114 FlBERGLA55 ® 8 FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 464.. _.-.-.-_ .-----..- ........................_-- SECONDARY CONTAINMENT [11.STEEL [1 4.FIBERGLASS ® 8 FLEXIBLE ❑ 10.RIGID PLASTIC 46,11a. ❑ 90.NONE [195.UNKNOWN [199.OTHER(Specify): 46e. ................_.-_.-._____-..___...._____._..___....._.-_-__...-_.-...-..__...-.._-.-.-..--._-_ ---------- PIPING/TURBINE CONTAINMENT SUMP TYPE 19 I.SINGLE WALL [12.DOUBLE WALL [190.NONE 4 VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 ,. ................. .._---.-_ ...-.-.-.-. -____-.._ _-HATH ____-..___ .............. ............ .. ................. .-.-_.- VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FlBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4�f: ___ _ _-__...._-__.-__ ........-_. ................ ................. ___--- VR PRIMARY CONTAINMENT ❑ 1 STEEL 0 4.FlBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4664 g: -._.____-.______________________________.................__ _--__________...__...-_____.___- __s_ VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify): 4 Ch1. ____ __ __________ ___............. .___..-.- -_.-_..._ .-.......- ._.._._.-____..... .______. . ....-_.-. -................. -.-.___-._ .._..._.. VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL [12.DOUBLE WALL [190.NONE 461. .__ . -----__.. .._.-._-_ - RISER PRIMARY CONTA . INMENT_ ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 j. .. ... ............. .._.-THAT_ -.. ._______ _.____.. . _..__....... .....-..--.. ._..._-__ .. ..._______. __.._ RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify). 46�k�. FILL COMPONENTS INSTALLED 0 1 SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451 a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL El 3r NO DISPENSERS [190.NONE 469a...... ... . . ir9h. CONSTRUCTION MATERIAL ❑ I.STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC [1 99 OTHER(Speedy) 169, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION -4e. 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 ' 1 DATE `70' es Ire/o a _ APPLICANT NAME(Print) Ian Moorhead 471 APPLICANT TITLE Env. Compliance Mgr. 472. UPCF UST-B Rev.(1212007)-1/2 www.unido".org