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sAWL FIED PROGRAM CONSOLIDATED I 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,17,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) - 1. 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 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 2 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 ❑ 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.OTHERGENERATOR FUEL............................................_0 95.UNKNOWN.........................._..-._..__......._......---... ......... OTHER(Specify): 439a. CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS -....._....._0.._8:.PETROLEUM BLEND FUEL............_ ..._9 OTHER PETROLEUM(Sped. ).:...... a40a. .............................................. 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 [__1U 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 ❑ 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 WALL ® 2.DOUBLE WALL [:199.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 ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE [1 95.UNKNOWN C] 99.OTHER(Specify): 464c. .............................................................................................................................................._............................._...._._....__.........._................................... PIPING/TURBINE CONTAINMENT SUMP TYPE ® L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION 464 VENT PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. ............................................................._._..---...._...._.......................__......._._.__................---......_..........................................._..................................................................................._.._..........................._..._.....__......_........................................................................................................................................ 464f. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464H ..............64......._ VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE [199.OTHER(Specify): Abgge ................................................_...._........................................_........._.................._........._............_...................................._........................................._........................................_...........................................__..................................................._............................................................................................................... VR SECONDARY CONTAINMENT [11.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hl. ..............................._............................_._._.............----.............._......................................................................................................................................_...............................__................................................_...................... ...................... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464i ..............._.................._..............._._..........---.................-................................._....._......_...................................._..............................._..._..............................................................................................._........_............................................................................................................................................................................_..........................................._.4.._......... RISER PRIMARY CONTAINMENT ® 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 4y11 ................_...---._.._........................................................_.._......._..............__...---..._............_...-..._...................._........................................................_.....................................................__........................_.......---.._..............-..__._........................................................................_...........I 464k. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): 464kl. __...--...._......._.._._......_..-_._.._........_._....._.................................................................................................................................................__..........................------...........__.._....._................................................................................................................................_... ..._... 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 [1 3.NO DISPENSERS ❑ 90:NONE 469a. ............................................................................. .............................................. ........................ ... ......... .. .. .................. .................... ..................................._.__._...._......._.................................._.......... 469b. 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 44s. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that is UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and i f compliancp with legal requirements. APPLICANT SIGNATURE: DATE 06/11/2009 470 APPLICANT NAME(print) Chevron r s Co./JIM HARTMAN 471. APPLICANT TITLE Retail HES Permit Desk 472 UPCF UST-B Rev.(12/2007)