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IED 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,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) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Chevron Station#208118 BUSINESS SITE ADDRESS 103. CITY 104. 3355 E Hammer Ln Stockton, CA 95212 IL TANK DESCRIPTION TANK ID# _-r^� p�,$ 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 ❑ 1b.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 ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ..........................................................................................................................__❑..._8:.PETROLEUM BLEND FUEL....._. ❑ 9.OTHER PETROLEUM(SPe�...... 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 [1N 443. 95.UNKNOW .................................. ....... 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 ❑ 99.OTHER 460. SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 12 CCR§2636(a)(3)] ass. _-...._._......... -_.._........................_..............................................................................................._._.._.........................._...-..-__.....--- ........._............._......................._...._......................................................................_................__._..._._...................................................................................................... PRIMARY CONTAINMENT ❑ I.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 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): 464e1. .........................................._...............................................-..._..._.._.........._..........................................................-.._.................._........_..._....................................._._..................................................._......_._.......--... VENT SECONDARY CONTAINMENT [31.STEEL [--] 4.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE [:199.OTHER(Specify): 464 -.. .........................................._............_............................................................................__.................................._....._......._.............._........_-..................._........-......................._............................................................................................... 464 . VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 e .........................................._..._..__........_..........._.._.............._................................................................................................_._.....................-----..........................._._.._......_..............._.........----................................__._....................................................................................................................... _�-.. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hh. ....................................................._.........................._..........................................................................................................__.......... ---........-....-........_.............._........__..._......----.........................................................................................................................................................._.... ----... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641 ...... .......... ........................................._.-...._...._..................-......._............................. RISER PRIMARY CONTAINMENT ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g46jl. .............................................................................................................................................--...._._......_.........----.........-.....................-...........__........._.................................................-.........................................-_..._..........-..._....................._... _........_.............._..............._. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE F-199.OTHER(Specify): 4464ki. ............................................................................................................................................_._..._-........._........_-._.....................-..._.................................................................................................. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NP114E,_ 469a. ................................... ............_.._........_........... ..._ ............................................ _..... -...................................._............................................................................................................................................_....._.__......................................... .............................._......_.......---........................................................................ ..... _s. CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIII, CORROSION PROTECTION ' _aa STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE 1 CERTIFICATION: I certify that thi US ystem is compatible with the hazardous substance stored and that the information pt%yided herein is true, accurate,and in f 1 com iance with 1 al requirements. APPLICANT SIGNATURE: DATE 06/12/2009 ;;f azo. APPLICANT NAME(print) Chevron Produ is ./J HARTMAN 471. APPLICANT TITLE Chevron Retail HE -*it Desk 472 UPCF UST-B Rev.(12/2007)