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' • DI I ori FIED PROGRAM CONSOLIDATED FOW UNDERGROUNDSTORAGETANK ✓ I OPERATING PERMIT APPLICATION- TANK INFORMATION (Onefofmpef UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 111,Iff,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: 430n 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ O 0 O _ 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 7-Eleven#32190 BUSINESS SITE ADDRESS 103. CITY 104 4943 S. State Route 99 Stockton II. TANK DESCRIPTION TANK ID#Q JF'�5/_ 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 003 Gf XeIXes ® I.A STAND-ALONE TANK Complete one page for each 2.ONE IN A COMPARTMENTED UNIT companment in the unit. DATE UST SYSTEM INSTALLED -J3 I TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437. 6/2003 10,000 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ 16.MARINA FUELING ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inchnue Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL HSC§2528I.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN [] 99.OTHER(Specify): 4391. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED 10 lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ S JET FUEL ❑ 6.AVIATION GAS _0_8_PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify)_.. 4411a. NON-PETROLEUM:❑ 7.USED OIL 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION _TYPE OF TANK D.1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT -._.El I.STEEL -------® 3.FIBERGLASS----0 6.BJTERNAL BLnnnER---------------`------'------------------- ______Y 0 77.STEEL+INTERNAL LINING ____❑ 95.UNKNOWN ❑ 99.OTHER(Specify)_ 444x. SECONDARCONTAINMENT [I1.STEEL M 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN_ [399_OTHER(Specify} 4451. OVERFH.L PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHI5R 40. SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY (]_3.CONVENTIONAL SUCTION ❑ 4.SAFESU_CI'ION 123 CCR§2636(1_)(3)] 458. PRIMARY CONTAINMENT - _- ____..-..-..-____ ___ _ _ _ ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE D 95.UNKNOWN _❑ 99.OTHER(Specify):__ 464x. SECONDARY CONTABJMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4645. 90.NONE __El 95.UNKNOWN _ 99.OTHER(Specify).--- 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE M 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY T CONTAINMEN464e. __ ❑ L STEEL _® 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464e1 VENT SECONDARY CONTAINMENT 13 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC R 90.NONE ❑ 99.OTHER(Specify): a46tl. VR PRIMARY CONTAINMENT 0 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC4648. ❑ 90.NONE ❑ 99.OTHER(Specify): �y 1 VR SECONDARY CONTAMENT IN ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): g64h1 _ VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL 0 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC 4641 _-___.._.__-_-..__--_____ ❑ 90.NONE ❑ 99.OTHER(Specify): __........._.__._.-__-.________ 464.,1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 46 Rl FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATF/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL 0 2.DOUBLE WALL -- ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. ..............__..................______....-_-______________._________ . CONSTRUCTION MATERIAL ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) °a46-9b.- 469c.__ VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 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 provided herein is true, accurate and in full com liance with legal requirements. APPLICANT SIGNATUREppTE 4m. APPLICANT NAME(print) Ian Moorhead APPLICANT TITLE 472. Env. Compliance Mgr. UPCF UST-B Rev.(1=007)-1/2 www.unidoclsorg