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U ED PROGRAM CONSOLIDATED FORIF <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION cone f.-per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections f,If,I!/,/V,and IX below) 430 <br /> ❑ L NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430., 1 DATE EXISTING UST DISCOVERED: 430b. <br /> I. FACILITY INFORMATION <br /> FACILITY ID It(Agency Use Only) _ O O Q _ 1. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> 7-Eleven#32190 <br /> BUSINESS SITE ADDRESS Ina. CITY IN. <br /> 4943 S. State Route 99 Stockton <br /> II. TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434 <br /> 002 Xerxes ® I.A STAND-ALONE TANK Complete one page for each <br /> ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. <br /> 6/2003 G-16-0 10,000 <br /> III. TANK USE AND CONTENTS <br /> TANK USE 0 In.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING 0 Ic.AVIATION FUELING 439, <br /> 0 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) 0 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] <br /> 0 6 OTHER GENERATOR FUEL0_9_5._U_UNKNOWN ❑ 99.OTHER439x. <br /> ____ "."...__ _ __s..". .._"._"____ _..______ .. (Specify):. _LE _ <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ® Ic.MIDGRADE UNLEADED ❑ Ib PREMIUM UNLEADED 44n <br /> 0 3.DIESEL ❑ 5.JET FUEL 0 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 44oa. <br /> ". .. __" ............. ......__ .... "............. <br /> NON-PETROLEUM:� 7.USED OIL ❑ 10.ETHANOL <br /> 0 11.OTHER NON-PETROLEUM(Specify): 440b. <br /> IV. TANK CONSTRUCTION <br /> .TYPEOFTANK0 LSINGLEWAL__L ­--l----------------------® 2.DOUBLEWALL___0 95.UNKNOWN 443. <br /> PRIMARY CONTAllNMENT 0 I.STEEL ® 3FIBERGLASS <br /> ......"."."....... <br /> ❑ 6.INTERNAL BLADDER 444. <br /> ___ 0 7_._STEEL+_ INTERNAL LINING___ _0 95 UNKNOWN _❑ 99.OTHER(Specify): 444a. <br /> SECONDARY CONTAINMENT <br /> [11.STEEL ®3 FIBERGLASS [j6-EXTERIOR MEMBRANE LINER ❑ 7.lACKETED 445 <br /> _ .___.____"._".".".".........................._.._ _90.NONE � 95.UNKNOWN 099..OTHER(Specify): 445.. <br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS 02.BALL FLOAT 03.FILL TUBE SHUT-OFF VALVE <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION 0 1.SINGLE WALL_® 2.DOUBLE WALL 0 99.OTHER 4W. <br /> _SYSTEM TYPE 0 I.PRESSURE ❑ 2 GRAVITY 0,3.CONVENT16NALSUCTION 0 4 SAFE SUCI1 ITION LDCICR§1636(a)(3)I 45& <br /> PRIv1ARY CONTAINMENT ".G <br /> ❑ L STEEL ❑ 4.FlBERGLASS ® 8.FLEXIBLE ❑ ]0.RIGID PLASTIC 464 <br /> 0 90.NONE __ _ _ ❑ 95 UNKNOWN 99.99.OTHER(Specify):. 464a. <br /> _________ "_."."."_ ......_.... <br /> __________ <br /> SECONDARY CONTAIN T ❑ L STEEL 0 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 44b. <br /> 0.,_9B:NONE_._______._0.95_UNKNOWN 99. (Specify): 464c. <br /> P�ING/TURBINE CONTAINMENT SUMP TYPE ® 1 SINGLE WALL ❑ 2.DOUBLE WALL 0 90,NONE 4644. <br /> VI. VENT,VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.STEEL ® 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 4Me' <br /> .... ..".............. _ _ <br /> -VENT SECONDARY CONTAINMENT 0 I.STEEL 0 4 FIBERGLASS 0 10 RIGID PLASTIC 0 90 NONE 0 99.OTHER(Specify): 464E <br /> 11 .. 464f1. <br /> VR PRIMARY CONTAINMENT 0 1 STEEL 0 4 FIBERGLASS 0 10 RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 4�s <br /> .............._.. ------------------------------______. _____-- - ........... ......._'-- __.."._. ................. ..." <br /> VR SECONDARY CONTAINMENT 0 1 STEEL 0 4 FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify): 464h' <br /> ..". ........._.____.. ...___..."... _..______ <br /> VENT PIPING TRANSITION SUMP TYPE 0 I.SINGLE WALL 0 2 DOUBLE WALL 0 90.NONE 464'. <br /> ..".............. ____. _______ __ ................ . ______ _ <br /> RISER PRIMARY CONTAINMENT 0 1 STEEL 0 4 FIBERGLASS 0 10 RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) <br /> ..."."........... _."_...."..." _._---- ._..____ _______--- ,,.,.,... _.____. .. ".---------- ------- <br /> RISER SECONDARY CONTAINMENT 0 L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC ® 90.NONE [399.OTHER(Specify): 4�k <br /> FILL COMPONENTS INSTALLED .. <br /> _ ® 1.SPILL BUCKET ® 3 STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c- <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® I SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.N 469e. <br /> .... ".".".". ". ............. .".".........." ........__. <br /> CONSTRUCTION MATERIAL 0 L STEEL 0 4.FIBERGLASS 0 10 RIGID PLASTIC 0 99 OTHER(Specify) $ ,`"-9 469b,-- <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT 0 6.ISOLATION 448 <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provid herein is true, <br /> accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANT NAME(print) Ian Moorhead 471. 1 APPLICANT TITLE Env. Compliance Mgr. 472 <br /> , <br /> UPCF UST-B Rev.(12/2007)-112 www.unidc cs.org <br />