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7I� ► o� Ak 'disk A-WIED 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 I,II,III,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: 430x. I DATE EXISTING UST DISCOVERED: 4306. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - 1 16 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 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. ® 1.A STAND-ALONE TANK Complete one page for each 3 03 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/ 1992 12,000 0 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.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 4a0. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _._....._..............................................................._ ..._8:._PETROLEUM BLEND FUEL. [1 9..OTHER PETROLEUM(SPeci.k)..:...... 440a. .............................................. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL [:1OW 95.UNKNOWN 443. .........................................................................................._._._..............---._..._._........................................................................................................................................................................................ PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER aaa. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444x. .............................._...........................................----._.........__..._.__..._......................................................................................................................................................_........................ ._............ ................................................... SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEBRANE LINER ❑ 7.JACKETED M 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 WALL ® 2.DOUBLE WALL [:199.OTHER 460. SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY [13.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 ❑ L 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 0 2.DOUBLE WALL ❑ 90.NONE 46 . VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® 1.STEEL El 4.FIBERGLASS [I10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 464ee�. . VENT .............. ----..............._.._..-_.._..._.....................__........................................................................................................................................--..._...----........_....._............_............................................................................................................................................................ 464f. 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): 4644 g ---=......................................_............................................................................................................................................................._...............- ........................ -&....._... 464h. VR SECONDARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): 464ht. ..........................._.........................................__...................................................................................................................................................................................... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. ......................_........._...._........._........._._............._......._......................................._.......................................................................................................................- -._...._... -._._............................................................................................................................................................................._...._.........................--...._............................. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC El 90.NONE El 99.OTHER(Specify): 464j. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): a464E ......_................._..._........................................................................................._...................................-............................_..........................................._..._-._..............................._................................................................................................................................................................................._..._.. ....................... 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 [1 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. .................................................................. CONSTRUCTION MATERIAL El 1.STEEL ® 4.FIBERGLASS [I10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTE ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify thatt s UST system is compatible with the hazardous substance stored and that the information proid ed herein is true, accurate,and'n ull com liance with legal requirements. APPLICANT SIGNATURE: DATE 06/08/2009 470 APPLICANT NAME(print) Chevr i Products Co./JIM HARTMAN 471. APPLICANT TITLE Retail HES Permit Desk 471 UPCF UST-B Rev.(12/2007)