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FIED PROGRAM CONSOLIDATED FOWI 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: 430a. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Chevron Station#201761 BUSINESS SITE ADDRESS 103. CITY 104. 1103 S. Main St. Manteca, CA 95337 IL TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 1 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. 11/30/1992 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 [195.UNKNOWN [399.OTHER(Specify): 439a. ..........................................._-....._........._...------............._....._....--............................................................................................................................................................................................................................................................................. ---.. CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS --.....................................__O.._8.PETROLEUM BLEND.FUEL............_ .._9:OTHER.PETROLEUM(Specifk').:_._ 44oa. ............................. ............. NON-PETROLEUM:[17.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): 444a. ---............................._....._....................................................................................._.................................................._......._..._....__.._........_.._.................................................................._............................................... ...................................445..... SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445a. OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL'-A'LARMS ❑ 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..............................................................®....1.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 [:1L STEEL ® 4.F.IBER...__G.........LASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE EI 95.UNKNOWN [199.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 ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC El 90.NONE El 99.OTHER(Specify): 46gel. _..._.............._........-.-..._.......................................................................:....................................................__._.............................................._.................................._._... f VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464£1 ........................._. .._......._.__....._...........................-_......................................................................................................._...............................................-......................_...................... ....................... .................................................................................................................................................................._..... 4648. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 46481.. .._.............................................................._................................................................................................_...- :._....- .._.__......._.............................._.........._................................................_..........................................................................................._.._...__.._........................-..................... VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hl. _........__................._......................................................................................................_....__......................._.....---._.._..............-.._.............................................................................................................................................................................................................._.............._.._..._................................... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464,. ..........................................-................................................_..................................._._._...._._.......................---............................._...................................................................................................................................................................._._.._.................................-....._.................................................................................................................................;_..... 4641. RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4641 ...................................................._....................................................._.._......---..................-...............__..._.._........................_...................................................._................................................................................................._...... -......__.........- 464k. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464kl. --..........................................._............._.............................................................................................................................................._................................................................_.........._._....................................................................................... FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® L SINGLE WALL ® 2 DOUBLE WALL ❑ 3 NO DISPENSERS [1 90 NONE 469a. ................................ .... ..... .. ....................... .... _...............__....... . .......................... .... ................................................... 4696 CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. M APPLICANT SIGNATURE CERTIFICATION: I certify that is ST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and i f om liance 4ith legal requirements. APPLICANT SIGNATURE: DATE 06/11/2009 470 APPLICANT NAME(print) Chevr n Pro is Co./JIM HARTMAN 471. APPLICANT TITLE Retail HES Permit Desk 472 UPCF UST-B Rev.(12/2007)