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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 I,A 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: 430.. 1 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. 1 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 1 VA0A63 p 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 ❑ 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)3 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. ...................................................................._.._........_....................................................................---....._......................................................................................-..................................................................................................................................- - .. .......440...... CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑..._8:PETROLEUM BLEND FUEL- 9 OTHER PETROLEUM..(SPecifY).:...... 4.4.0!. .. 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 ❑ 95.UNKNOWN 443. -- ..... ............................... ........ ............ ... .. .... PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. ........................................................._.....................----...._......._.....__._.............................................. .................................................................................................................................................. SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS [16.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. _ ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. .........................................................................-.....................__.._-.........._........---....................................._........................ .-----......_......_...._ OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS [12.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPINGCONSTRUCTION ❑ 1.SINGLE WALL ................ ............................ ............._.................................... ............ ............................................................................ ............_.... SYSTEM TYPEI.PRESSURE El 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 464e. VENT PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. ....................... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464fl. ....................... VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 461 B ... ............................................................................................................................................................................................................................................_........_-.................................................................................................................................................................................................................................................. K.......... VR SECONDARY CONTAINMENT [I1.STEEL [I4.FIBERGLASS [I10.RIGIDPLASTIC ® 90.NONE El 99.99.OTHER(Specify): 464h1. ........................................_.................................................................................................................__...._..._.._............._.....---._.............----................................................................................................................_......................................._..................._...__....-....... ........_._._......................... VENT PIPING TRANSITION SUMP TYPE [11.SINGLE WALL [12.DOUBLE WALL ® 90..NONE464. .................................................................................................................................................................................................._......................................_..........................................._............................................._.................................................................__......................................................................................................................__................................................ RISER PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify):fY) 464j.. - ..._............--..__...................................................................................................................................................................................................................................._......_............ 46411. ...... 464k. RISER SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464kt. ..........._..........................................---........_......................._......._............................_..............................................................................................................................._.......:.................__............:...................._........................................................... ....................... FILL COMPONENT$INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) ' CONSTRUCTION TYPE ® L SINGLE WALL ® 2.DOUBLE WALL [13.NO DISPENSERS ❑ 90s I 469a. ................................................._...................................................._........................................................................................................................................._..............................................._................................................................-................................._...................................................................................................................a....................................._............... CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) , . -.- 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I rtify t this UST system is compatible with the hazardous substance stored and that the information provided herein is true, ace rate a in full com liance with legal requirements. APPLICANT SIGNATU DATE 06/08/2009 470 APPLICANT NAME(print) C ev Products Co./JIM HARTMAN 471. APPLICANT TITLE Retail HES Permit Desk 472. UPCF UST-B Rev.(12/2007)