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LOWFIED PROGRAM CONSOLIDATED FO / )� /O UNDERGROUND STORAGE TANK l / L 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 I,II,III,IV,and IX below) 430. ❑ I.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: 430x. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Chevron Station#201383 BUSINESS SITE ADDRESS 103. CITY 104. 1960 W 11th St. Tracy, CA 95376 11. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. ® 1.A STAND-ALONE TANK Complete one page for each 2 T D XERXES ❑ 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. 12/1 1992 12,000 0 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: ❑ la.REGULAR UNLEADED ® lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS .........................................................__..........................................._._............_�..._8.PETROLEUM BLEND.FUEL............_❑..._9.OTHER PETROLEUM SSRecify)........ aaoa. ............................PETROLEUM 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. ❑ STEEL+INTERNAL LINING ❑ 95.UNKNOWN [199.OTHER(Specify): 444a. ... 7................................................................................_.........................................._........................._......._.....---._............__................._.__..._..................................................................................... .............._......................._.._..... SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN [199.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 WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ® L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. .. ....._..._ _..._.........................._...._........................... ............ ................ ........................................................................................................................--._..._._..._.._.-_...................................................................................... _..............__.._.................................. .............. ...................................... .... _......... _ PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. ...................... . .-...................................__._..................-.__.-.._.........._....................- ........................................................................... ...._..........................._........... SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 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 [:14.FIBERGLASS [I10.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 4a6ae 1. ---..__ .........__..............................................................................................................................................................................._..._................................................._...................................................................................................................................................................................................._.._....._. VENT SECONDARY CONTAINMENT [11.STEEL [:14.FIBERGLASS [I10.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): 4.. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a�g. .._._.__.........................................................................................................................._....__........_._..._._..........-...._....__............---......_..............................................................................................................................................................._.........................._......._.__.............---._.._..._..... _.is.......... VR SECONDARY CONTAINMENT [11.STEEL [14.FIBERGLASS [:110.RIGID PLASTIC ® 90.NONE [1464h.99.OTHER(Specify): 464h1 -- ..................................._._..._.._.__......................................_............................................................................................................................................................................................... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 96.NONE 464i _............--.._........._.._....._...._._.._....................................................................................................................................................................................................-.................................__..................._.__....................................................................................4j....... 464j RISER PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER S eci . RISER SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS El10.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): a6ak1. __....._ FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑'90:NOdIE 469a. .. ............................................................................................................._......................._.........__......._.....................................:...:_... .............................................................. CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696. VIII. CORROSION PROTECTION , STEEL COMPONENT PRO ION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448, IX. APPLICANT SIGNATURE CERTIFICATION: I certify tha this UST system is compatible with the hazardous substance stored and that the information provided herein is true, k accuate,a in full co liance with legal requirements. APPLICANT SIGNATURE: DATE 06/08/2009 470. APPLICANT NAME(print) C e Products Co./JIM HARTMAN 471. APPLICANT TITLE Retail HES Permit De „` 472. UPCF UST-B Rev.(12/2007)