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(e'�1-3i0q �ti1►ti IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal, complete only this section and Sections 1, 11, 111. /V, 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: 430a. I DATE EXISTING UST DISCOVERED: 4306. I. FACILITY INFORMATION FACILITY M # (Agency Use Only) 1-1010101-1 BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 7 -Eleven #19976 BUSINESS SITE ADDRESS 1113• CITY 104• 1399 N. Main ST. Mantenca II. TANK DESCRIPTION TANK m # *6,E�GP� 43'--• TANK MANUFACTURER 433• TANK CONFIGURATION: THIS TANK l5 434 002 Xerxes ® 1. A STAND-ALONE TANK Complete one page for each ❑ 2. ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435• 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 ❑ Ib. MARINA FUELING ❑ lc. AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a. CONTENTS PETROLEUM: ❑ Ia. REGULAR UNLEADED ❑ ]c. MIDGRADE UNLEADED ® Ib. PREMIUM UNLEADED 440• ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8 PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440a. ----................. ............ ......__...........__.................... NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 440h. IV. TANK CONSTRUCTION UNKWN 443• TYPE OF TANK ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 95. NO ___........... .......... ........... _.......... _._.... _...........__... PRIMARY CONTAINMENT ❑ 1. STEEL ® 3. FIBERGLASS ❑ 6. INTERNAL BLADDER - -- -- ---�. ...___..... ..................❑..._7. STEEL + INTERNAL LINING 95:. UNKNOWN 0. 99. OTHER (Specify): 444a. --____._............_......._Q _ SECONDARY CONTAINMENT ❑ I. STEEL ®3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445a. _ OVERFILL PREVENTION ❑ 1. AUDIBLE &VISUAL ALARMS ❑ 2. BALL FLOAT ® 3. FILL TUBE SHUT-OFF VALVE 43z. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ L SINGLE WALL ® 2. DOUBLE WALL ❑ 99. OTHER 460. - .....................-...... ..._._.._...._.._......_ __..._...._.__...._...._.................................... .. ...................._..... _..______.................. ..._....................... .-.----•------------ _ .._.. SYSTEM TYPE ® I. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3p 458. _....._...............................-.-._....................................................................................................--...__._....__..__.............................................................. ... ............................................................. __............................................ __........................ _......._........_._.__......---....._......_._.........._...._._.......__.. PRIMARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ® 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464• ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464a. 4. FIBERGLASS ® 8. FLXIBLE ...................... ❑ 10. RIGID PLASTIC - _.._._... 464b NDA . SECORY CONTAINMENT [31. STEEL - -- [1E 90. NONE 99.OTHER (Specify):...... 464c. ...__............_....._❑..._95:.UNKNOWN _.. ...................._. _. ..._.._.._.......................464d...... PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1. STEEL ®4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4641. . 4641 1. _ ... ... ..__..............................................................._....................................................................................._-..............._......................._..............................................................................................................................................................................._. .. VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE [1Y 99. OTHER (Specify): 464L 464f1. VR PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 446 B .-.... __.......... _.............. _..... _.... __._.-.-._............. ........................ __... _.._.... _................... _.._........... ...................................... ................................................................................ __......_....---.... __.......................................................... _.................................................... _..-..... ---........................... B._..... VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 464h. ...... _........_..............._...._....._.._--.._ _.._._._...........-......... 464h1. _..............................................-._.__...._................................................................................_......__......................................................._..............._.................._.._............................__.._....-..___..................... ...._....,....... VENT PIPING TRANSITION SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4Mt' ................ ..................----------------....._.-.............. _...._..__.._.._.._................_................_........................................................................................... .................... -__......_..-----...._....._......... _.. _._...__....._..._.-..---.................... .................................................... ......... .-.._........ _..................4�....... RISER PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 46 j -........................................................... _._..................................................................................................................................................................................._..._......---................................................................................................................................................................................ d.......... RISER SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 464k. ................................................................................................... 464k1. FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a. -............__.........._................................__......................_..........4_... 69.- CONSTRUCTION MATERIAL ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODF(.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 compliance with legal requirements APPLICANT SIGNATUREDATE /3r �CP 470' APPLICANT NAME (print) Ian Moorhead 471. APPLICANT TITLE Env. Compliance Mgr. 471 v_ rSu9 UPCF UST -B Rev. (17/2007) - 1/2 www.unidocs.org i