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IED PROGRAM CONSOLIDATED FOMW RECEIVEDVk - e UNDERGROUND STORAGE TANK *1 OPERATING PERMIT APPLICATION-TANK INFORMAT N (One form per UVl') TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,77,III,IV,and IX ) 430. ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL SAN DATE UST PERMANENTLY CLOSED: 430a. I DATE EXISTING UST DISCOVERS fib. I. FACILITY INFORMATION _.4 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#,1p ' as,6?,� 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 ❑ ic.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 El 95.UNKNOWN ❑ 99.OTHER(Specify)_ 439a. ._................................._........_._. ............................................................................................................_.__............. ..4.....I .. CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED ❑ 40. 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _❑ 8.PETROLEUM BLEND.FUEL 0„9.OTHER PETROLEUM(Specifx) 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 ❑ 95.UNKNOWN 443. ❑- .. ....._...,..........._..._._.-................................ ................................................................. ........................... . . ... .. -._._._. .. -. .... ............ .....444...... PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER ❑ 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 RE UIRE1vIENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. ............................---.-...................................................................................................................................................................----........._.........-.._..............................._.........................................................................................................................__........................................_........................._._......._.............._ SYSTEM TYPE ® l PRESSURE 0 2.GRAVITY .._...._.........__0..._3..CONVENTIONAL SUCTION El 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. MENT _. PRIMARY CONTAIN ❑ 1.STEEL 04.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. _._......._...........__.._........._..:._0.._90.:NONE................................❑.._95:UNKNOWN....._........__._�.._99:..OTHER(Specify):._.. 464a. ................. ........ --- _ ......_... SECONDARY CONTAINMENT [11.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. .........................................:.................................................................................. --...._.._........... PIPING/TURBINE CONTAINMENT SUMP TYPE 01.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 [190.NONE [199.OTHER(Specify): 464el. . . _.. .._._..........._._.__... ._..-...--........_.......__................................................................................................................__._.._............................__............................._. .. . ............ . ---............................................................................................................................. __.... a6af VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464 ..................._........-..__._........_._........._......................................................................................._................................_...._... ....464 g. ....._ VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99 OTHER(Specify) 464s......, .......................__.._............_..........................................._......................................................_......................_._.._......._................_.._.......-...........--- --......-_......................._-...................................... . . 464h. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464h1. ......_._..........._......_...................................._....--..---..........................---._...................---.............-._._......._...- .----......................................._..............................................................._.............._.......___ -................................. ..................... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4��' -......----...._._.._.........................................................._........................................................._........._............_.._ __..........................._......................................................................................................_-..............._..-........................................................................._......_..............................................64....... RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464641..,,.., ..............................................---....................._...................__._....................................._.........._......................-----.............._.._...._.............................................................................................................._......................_---- ---....._.................................................................................... RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIB GLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): a54k1. _..._........................_.._._..._...................................................... _.....................- ----- --......................................................................................_..........................__....................... _...._ FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET 3.STRIKER PLATEIBOTTOM 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. .._........._...................._......_...........................................................................................................................................__........._.............----..........................................._......._......................._._..................................................................................................................................._........................_........_...-._..........__........._.............................................. 4696. 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 UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurst ,and in full compliance with legal requirements. APPLICANT SIGNATURE: wo91•tARVAEZ DATE 01/13/2009 470 APPLICANT NAME(print) 471. APPLICANT TITLE 472. (P ) Chevron Products Co./FRED MARTINEZ Retail HES Permit Desk UPCF UST-B Rev.(12/2007)