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IED PROGRAM CONSOLIDATED FOMW „n ,p UNDERGROUND STORAGE TANKKK G 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) a3o. ❑ 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) - '- L 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# D z58Ba 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 7 1.A STAND-ALONE TANK Complete one page for each 2 XERXES ® p p s ❑ 2.ONE INA 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)] _.._.-0 6:OTHER GENERATOR FUEL ❑ 95 UNKNOWN ❑ 99.OTHER(Specify): 439a. --..... ..........................__....................__----............-._.._....................._...................................................................__...... .......440...... CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ® Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑..._8 PETROLEUM BLEND FUEL......_...._ 9.OTHER PETROLEUM(Specifk)...... aaoa. ........................... _._..... 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 443. ................................................___..__....._..__._._........................................................_-........_......_........................................................................................................................._-..........................._-._..............................................._.........................................................._.............................................................................................................. PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 44a. El 7. +INTERNAL LINING -- [1 95..UNKNOWN _..._❑ 99:.OTHER(Specify) 444a. ......................................... ----._..... SECONDARY CONTAINMENT ❑ 1.STEEL .0 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 4a5. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. ----..........._..._..._.................................................................--._................._..._.._._.................................................................................................................... ................................................... OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452. E] 4.TANK MEETS RE UIREMENTS 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 ❑ 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION[23 CCR§2636(a)(3)] 458_ PRIMARY CONTAINME&T ❑ 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 ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. -.............-_...._........................--...._......._.................._....._.............-..................................................................................._......_._._.................._.._....... PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641"' VI. VENT,VAPOR RECOVERY(VR)AND RISER I FILL PIPE PIPING CONSTRUCTION 464 VENT PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464et. ...................................................................................................................................._...__................................._._................................-................._.-...._......................................................................................................................._-.....................__...-..........................._...................................... ................... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4q fl£ .................._..__.......................-......_.....-_......................._..__........................._................................................................................................ ...................._. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464�g ........................................................................................_._......._.-...._............................._._.................._..._..-........................__................._......................................................................................................._._...._........._......................__._..............................-_..................__.................... VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464h1. __......_......_....._.._..-........................................................................................................................_._.................................---.........._........_............__._.-_.._.....---...........................__............................................................................................_.._......................__........................ .... ._.. VENT PIPING TRANSITION SUMP TYPE [1I.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE q�` ..............................................__....................._.._-__..._._..--._..........................................................................._.........._...................---........................._...._....._.................._................._..._................._........-........................................................................................................................4�.... RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464J._._. _...................................................................................................................................._._..__........__...---............................._....._.............._._...._.....__-..._...--.................................................................................................._._......................_.............. .. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): A1. 46441. _....--...-...._ . .........................................................................................._...__...........................__................._...................................................................................................................................................-......................................... ................... ..................... FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 45la-c. VIL UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL..................................................................._[1 2:._DOUBLE WALL................_[1 3:._NO DISPENSERS...................-0.._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, accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE: DMAR779JEZ DATE 01/13/2009 470 APPLICANT NAME(print) Chevron Products Co./FRED MARTINEZ 471. APPLICANT TITLE Retail HES Permit Desk 472 UPCF UST-B Rev.(12/2007)