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r / IED PROGRAM CONSOLIDATED FOMW UNDERGROUND STORAGE TANK tS OPERATING PERMIT APPLICATION-TANK INFORMATION (One fo per ) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,11,111,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: 430x. 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#208118 BUSINESS SITE ADDRESS 103. 1 CITY 104. 3355 E Hammer Ln Stockton, CA 95212 II. 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. 07/15/1999 20,000 0 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ ic.AVIATION FUELING 432 ❑ 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. ......... .........................................................................._...._.............................................--_..................._..........-----..._.... ....... CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED aa0. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _._.._.................... -- 0..._8:PETROLEUM BLEND FUEL...._._ 9.OTHER PETROLEUM(Specify):...... 440a. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK 0_._1.:..SINGLE.WALL.......®..2 DOUBLE WALL.........._0....95.UNKNOWN................................................................... 443. ---- _ __._.._._.. .............................._......._..............._......................................_.................4...._ PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4� _- ❑ 7:STEEL+INTERNAL LINING _ ❑_95.UNKNOWN ❑ 99.OTHER(Specify): 444a. SECONDARY CONTAINMENT 0 ....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 C1 ...................................... 99.OTHER 460. _....__....._......-............_...........__._............................................................................................................................._............._._..._.-.........................__.._.............._....._...._....._._.................................................. ....................................................... _.....__............ SYSTEM TYPE _ ® 1:PRESSURE [1 2.GRAVITY ❑ 3:CONVENTIONAL SUCTION [:14 :SAFE SUCTION[23 CCR§2636 (a)(3)] _ 458. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE 0 95.UNKNOWN ❑ 99.OTHER(Specify):. 464a. SECONDARY CONTAINMENT [11.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC a6ab. ❑ 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 [14.FIBERGLASS [110.RIGID PLASTIC [390.NONE [:199.OTHER(Specify): q4�j .. . . . . . . . .. . . . . .. . .. ....................................................._............-................................................... ..........._._..._ VENT SECONDARY CONTAINMENT [__11.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464 _- ---..........................._........_...........................................................................................__._ ......................_._.. _.......-----.............................._._....__............................................................................._._._-...._.___.__ 464g. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464.1. ............._........._..........................................................................................._.....................__..._....._................._.. ....._...--.._......._......._....._..__.._........................................_..._........_......................................-_....................................__....._.............................-................ VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FMERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464h1. ........................._............................._......................_....._..._._...---..._...._---......................._....._.................................._.._......_....................................------.........................---.._........................_................................................................................................................................-................. 46ai. VENT PIPING TRANSITION SUMP TYPE [11.SINGLE WALL [12.DOUBLE WALL ® 90.NONE ..............._......._.__._._......._...................._._.._............................................................................................................._...................................._-.._..._........-.._.............._..................................................................................... 4 ;..... RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS [1 10.RIGID PLASTIC 1--] 90.NONE [199.OTHER(Specify): 46411. RISER SECONDARY CONTAINMENT [31.STEEL F-14.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): 464kl. ...__.._.._..............._....---..................................................................................................................................._.._.__._-------._._....--.................................................._...............................................-_.........................................__............._..............._......._..._._..._._.. ...................... FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 45la-c. VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® ].SINGLE WALL ®..2.DOUBLE WALL..............._0 3„NO DISPENSERS...................0 90.NONE...... 469a. .................... . 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:IFT,,EtD MArIj71NEZ DATE 01/13/2009 470 (print) 471. APPLICANT TITLE 472. APPLICANT NAME (p ) Chevron Products Co./FRED MARTINEZ Chevron Retail HES Permit Desk UPCF UST-B Rev.(12/2007)