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UWS ED PROGRAM CONSOLIDATED FORW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One farm per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,II,Ill,N,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: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ 0 0 Q _ 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. 7-Eleven#32190 BUSINESS SITE ADDRESS 103, 1 CITY IN. 4943 S. State Route 99 Stockton II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 001 X0PX05 ® 1.ASTAND-ALONE TANK Complete one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT companmeot in[he mit. DATE UST SYSTEM INST LLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437' 6/2003 U'1a'ti�) 15,000 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ If.MARINA FUELING ❑ 1c.AVIATION FUELING 432 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Incidea Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC¢15ie1.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. ..............................-...-._-_-..______.___________-.__...._.._............____________.___ __.___-._-.-._..____ ._- CONTENTS PETROLEUM: ® Ia.REGULAR UNLEADED ❑ Ic.MIDGRADEUNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440x. NON PETROLEUM ❑ 7.USED OIL ❑ 10 ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 94W IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL _ ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4- _ ❑ TSTEEL+INTERNAL LINING ❑ 95.UNKNOWN [199.OTHER(Specify) 444a. DARY ..... .-.-.-.-..__ ____ .... ..... AS .-.__. SECONCONTAINMENT [1 L STEEL ®3.FIBERGLS ❑ 6 EXTERIOR MEMBRANE LINER ❑T JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 443a. OVERFILL PREVENTION to 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ L SINGLE WALL M 2.DOUBLE W ALL ❑ 99.OTHER 464 SYSTEMTYPE ® (.PRESSURE ❑ 2 GRAVITY _ ❑ 3 CONVENTIONALSUCPION ❑ 4.SAFE SUCTION I3N. CCR g2636(a)(3)I 45 PRIMARY CONTAINMENT ❑ L STEEL ❑ a FIBERGLASS ® 8 FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4640. ......-.. __. .......----------- ... _ SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4 FIBERGLASS ® S.FLEXIBLE ❑ 10.RIGID PLASTIC a64b. ❑ 90.NONE [195.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPINGn URBINE CONTAINMENT SUMP TYPE ® 1.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 [310.RIGID PLASTIC [190.NONE [199.OTHER(Specify): qWe. ---------_____ ..__-------_._ ................. ..______.. VENT SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99 OTHER(Specify): 4Nf1. __________ .....--..-........ .-. _.....-. ..-....-....-....-..... VR PRIMARY CONTAINMENT ❑ 1 STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC [I 90.NONE ❑ 99 OTHER(Specify): 464 g. _ __ s__ VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4 FIBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): q,h, .. ._.-_._..____ ............. ..._--.-_.-_.._ -_. .......-. .-_ VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2 DOUBLE WALL ❑ 90.NONE RISER PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify) q j; ............. ....._____ ....-.-... .._____.._.. . .-_____.._ RISER SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC R 90.NONE ❑ 99 OTHER(Specify): g466M1,1 _____ .............. .. .._____-.-. _._..__________ FILLCOMPONENTS INSTALLED ® L SPILL BUCKET ® 3 STRIKER PLATFIBOTTOMPROTECFOR ❑ 4.CONTAINMENT SUMP 451a, VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ML SINGLE WALL [12.DOUBLE WALL ❑ 3.NO DISPENSERS [390.NONE 469-. ar+mr.,�. CONSTRUCTION MATERIAL ❑ 1 STEEL N 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 99.OTHER(Specify) .�,:;$ 4696.469i VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION �,-:.` 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provide .h#in is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE '7- DATEr3 f (C .0 410 rL APPLICANT NAME(print) Ian Moorhead 471. APPLICANT TITLE Env. Compliance Mgr. TM472' UPCF UST-B Rev.(12/2007).1/2 www.unidocs.org