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AINk IED PROGRAM CONSOLIDATED FOMW �y J� UNDERGROUND STORAGE TANK d/1� � j OPERATING PERMIT APPLICATION-TANK INFORMATION (One form p r 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) _ _ 1 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 II. TANK DESCRIPTION TANK ID# j tq O 2 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 2 4 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 15,000 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 ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. ........ ...........__.................................................................... ........ ........................................................_._.. ....................... CONTENTS PETROLEUM: ❑ I a.REGULAR UNLEADED .0,NWb.MIDGRADE UNLEADED b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL 6.AVIATION GAS ......................._....._.-_......................................---._................_.._P...-B:..PETROLEUMBLENA _FUEL............_Q._9:_OTHER PETROLEUM S eci.k).:...... 440a. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK131.SINGLE WALL ® 2.DOUBLE WALL [195.UNKNOWN 443. _................................--- .................__ ._.._......................_..._.....................................................-................................................_..._.................-.._..._.................-_.........._..............._.............._.............................................................................................................................................................................. PRIMARY CONTAINMENT El 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4aa. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): aaaa. _............................................. ............... ........................_._..............._.........................................................................................................._._._..._._...._... ..... .........._.._..__.............................................................................................. ............................................._.... SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN [199.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 [199.OTHER 460. ._... .--.......................................................................................................................................................................... SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(x)(3)] 458. .... .......................................................................................................................__..._......................_..._.__._..................__........................................_._............................................................ PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC aha. ❑ 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 a6ad. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. ...................................................................................................._-._......_................................__............._......_......-_.....------._......................................................................................................_............._._......_...-............- -.-................._.._.................................... .................... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4 flf ...........................................-.-...._.........._..................................._..................................................................................................._.....................................-_................................_..._..............._................._...................._._..................................---...................................................................................................... ....................... VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464. ......................................................................._..............................................................................._.......................................---..___....---................................................................................................................................................_...................................---..._...........__..................................... 464h. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): 464hl. ...................... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464` ......................................-_-----._.................................__.._........................................_..................................................----...............---...-..........._....-............................................................................_.................................................................................................---................................................................................4�,...... RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g464j. .............................................._..............._.................................._......__..................................._...._..........._...................---....._. ..__......................................................................................................................................._........................._-............_.._.........................:........... RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4641. _ _ ...............................................................................................................................................-_._..................._._...._..__............._.__..._............_...................__.................................................................................................................................. 451 a-c. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP VIL-UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. ..............................................................................................................................................................._......__.._................................................................................................... ............................................_..-�---..._._............................_.__........................................................................................................................................._-..................__...---... CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696.469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 'A7 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that t is US ystem is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and iA full com liance with legal requirements. APPLICANT SIGNATURE: DATE 06/12/2009 `°' 470 APPLICANT NAME(print) Chevron Pr du Co./JIM HARTMAN 471. APPLICANT TITLE Chevron Retail HES Permit Desk 472 UPCF UST-B Rev.(12/2007)