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ED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION- TANK INFORMATION (One foim per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,II,!I/,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: 43oa. I DATE EXISTING UST DISCOVERED: 4306. I. FACILITY INFORMATION FACILITY m#(Agency Use Only) -10 0101-1 1, BUSINm ESS NAME(Sae 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#Z?5-16-1 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 002 Xerxes ® 1.A STAND-ALONE TANK COmPIMe one page for each 435. ❑ 2.ONE IN A COMPARTMENTED UNIT cempanmem in the unit. DATE UST SYSTEM INSTALLED TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UMT 43'1. 6/2003 10,000 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lndudea Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 4252815(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439x. Iiii�66iEW - _ _ CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ® lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 660 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ______________________._________.R.8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 44ua. _ __-.________ _______.___ _ _....._____ NON-PETROLEUM: 7.USED OIL �10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ I.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 944. ___ _�_7.STEEL+INTERNAL LINING ❑ 95_UNKNOWN ❑ 99.OTHER(Specify): 446e. SECONDARY CONTAINMENT ❑ 1.STEEL --..._.._.-____A,,S.........._.._._.._ ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LMER ❑ 7.JACIfETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTIiER(Specify): 445a. OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 652. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION [3 1.SINGLE WALL ® 2.DOUBLE WALL [199.OTHER 460. SYSTEM TYPE __ _ ® L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SU_C_RON[2_3_C__CR 42636(a)(3)1 458._ _ ___________.._ __ PRIMARY CONTAINMENT _ _______ ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE � 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.DINERS(Specify): ERGLA464a. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBSS ® 8 _- .FLEXIBLE ❑ 10.RIGH PLASTIC Gblb. __---________________ 0 90.NONE_ ❑ 95.UNKNOWN ❑ 99.OTHER(specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBIB W ALL ❑ 90.NONE 4644, VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL W 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE_❑ 99_OTHER(Specify): _________ 464f1. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): u464�_gl_. -- ___ -._ _ ............._ '--- .. ____ ___ VR SECONDARY CONTAINMENT � 464h. ❑ 1.STEEL (] 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): g6ght VENT PIDING TRANSITION SUMP TYPE ® L SINGLE WALL ❑ 2.DOUBLE WALL664i. ❑ 90.NONE RISER PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): ��_ RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC _® 90 NONE ❑ 99.OTHER(Specify): 444644 FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECCOR ❑ 4.CONTAINMENT SUMP 45la-c.- VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 3.NO DISPENSERS 469.. ❑_90.NONE _ CONSTRUCTION MATERIAL 6-1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696. d69c. 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 provided herein is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE �_ DATE 470. APPLICANT NAME(print) Ian Moorhead 4n. APPLICANT TTI'LE Env. Compliance Mgr. 4'2 UPCF UST-B Rev.(11!2007)-112 www.unidou.org