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AOL FIED 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,Ill,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, 1 CITY 104. 1103 S. Main St. Manteca, CA 95337 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 3 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 ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. .............................................................................._._. .........._._..........._..........................................................................................................................................................._......................................---.._._..................._...---.................................. ....................... CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTFIER PETROLEUM(SpecZ 440a. ..... .... ............ ... .............._....................._. ....... . . .. 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 -_._..__...---....................................................................................................................................................................................... .............._.................._..............................................�3:...... PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN [399.OTHER(Specify): 444a. ..............................._........_.._..........................................................................__......................................_......................................_..._........__..................................-............................................................... SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95...UNKNOWN [199.OTHER(Specify): 445a. .... ........._............................_......_......................................................................................................_...I.......................... .................................................. 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 ® I.PRESSURE ❑ 2.GRAVITY [13.CONVENTIONAL SUCTION [14.SAFE SUCTION[23 CCR§2636(x)(3)] 458. ..................................................................................._-_...........-------........................................................-..............................................................................................................................................._...................................................._....................._.................................... . PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. __..........._..............._.......---.................._....__.._.................................................................................................................................._-..........................._... ..... SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS E 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 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 ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46641. .................................................................................................................................................................................................... -..................._-................................................................................................................................................................................_.......................................................................... VENT SECONDARY CONTAINMENT [:11.STEEL [14.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): 4646171. .... ............................................................................._..........................._.-...................---........._...................................................................................................................................._....................................._.._............................................................. .................. ...... .... . ...................._............................................... ...... 464g. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a6ag1.,.__. .........................................................................................................................................................._......................._..........._..........._..._..._........._....._......................__......................................................................................................_..........._............- ....................._................................................... Oda VR SECONDARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE [:199.OTHER(Specify): 464hl. .............__.........._...................................................................................................................__..._....................__........................................_......................._.............._........................................................................................................._...................._._.._.................................................................................... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL IS 90.NONE ..._........................................................................................................................._..__....................................._....................................................................................._.........................................................................................__................................_._.................................................................................................................................................... .t..a..,...... RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify):._............ 464Jj ..._..._............._............................................................._._.............................._....-...._._...........--...__......................................................................_..._.....................................................................................__.................................................._............................_......._................................... RISER SECONDARY CONTAINMENT [11.STEEL [14.FIBERGLASS [I10.RIGID PLASTIC 0 90.NONE [399.OTHER(Specify): 464k. ......................................................................................................................__...................................._..._.._.._.......................__..._._...................................._......................_......................................................._....................................................................................................._........_....._......._._........................ ................._.. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451a-c. VII. ,UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 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 448, IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this T system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in ffill c m liance with legal requirements. APPLICANT SIGNATURE: DATE 06/11/2009 470 APPLICANT NAME(print) Chevron Pro CoJ JIM HARTMAN 471 APPLICANT TITLE Retail HES Permit Desk 472 s UPCF UST-B Rev.(12/2007)