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L� I :IED PROGRAM CONSOLIDATED XFRM UNDERGROUND STORAGE TANKS OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II, III,IV,and IX 430 below) ❑ 1.NEW PERMIT ❑ 3. RENEWAL PERMIT ® 5.CHANGE OF INFORMATION El6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I I I - I I 1 1 - 11 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 7-ELEVEN INC#35355 BUSINESS SITE ADDRESS 103 1 CITY 104 3202 W HAMMER LANE STOCKTON II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 1 --re;5c-� XERXES ®1.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 N/A 10,000 1 III.TANK USE AND CONTENTS TANK USE ® 1a.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ 1c.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: ® la.REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADED ❑ 1b.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): 440b IV.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): `tea SECONDARY CONTAINMENT ❑ 1.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 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ® 2.DOUBLE-WALLED[199.OTHER 460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE 464a SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d 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) 464e VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464f VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464h VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464i. RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL ""jg,_4.Fj J`B jRC,�LASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k ArAkj FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451 a-c VII. UNDER DISPENSER CONTAINMENT(UDC) ` -� CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE;;° 469a CONSTRUCTION MATERIAL ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 446. 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. t"�' " ?e'x t 10/27/11 APPLICANT NAME(print) 471. 1 APPLICANT TITLE 472 BREANNA HARMON REGIONAL ENVTL COMPLIANCE SPECIALIST UPCF UST-B Rev. (12/2007)