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IED PROGRAM CONSOLIDATED FORW 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) 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Chevron Station#209167 BUSINESS SITE ADDRESS 103. CITY 104, 1234 Yosemite Ave Manteca, CA 95336 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. 07/25/2000 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)] ❑.. OTHER GENERATOR FUEL..................... --- ❑ 95.UNKNOWN............................................................_......................................._[1 99.OTHER(Specify): 439a. CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 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. .............................................................................._._.............._.............__............................................_.__.._............_...................__..........._.................................................................._.................................................._........ 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 ®..I.-PRESSURE ❑ 2 GRAVITY ❑ 3:CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. ..._ ..........................--........................... --..._.._.. --............................. ..................................... . .......... ... .................................................................................. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. _.._.__..................._......_.................._...._.._........_.................................................................................................................._..__._.. ....................................._............... . 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 ® L SINGLE WALL [12.DOUBLE WALL ❑ 90.NONE a6aa. 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): 4464�e1. ..........................................................._................................................................................................................................................................_..._........_......_........_.._._._.__....._......... _..._......................_...................................................................................................._.............................................. 4el....... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464£1 ..........................................................................................................................................................-.............._-._..................................................................................................................._......................................._......................................_..........................................-_................._................... ....................... 464g. VR PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS [I10.RIGID PLASTIC El 90.NONE El99.OTHER(Specify): 46a 1. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hl. ......-_._.-............................_......._..._...._................................._..........................................................................................-....._. __.._.............._................................................_......_.......................................................................................................................................................... _.._._.._._ VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. ...................__.........._..........................................................._........._.............----._.........._................----................................-...--.................._.-..................................................................................................................................._....__............................................................................................................................................................................. RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90 N 464j. ® ❑ ❑ .._❑ ONE ❑ 99.OTHER(Specify): RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): a64k1. ....................... ................_....................._....................................................................................................................._........................................................._..._._..._...........__........................_............................................................................................................................................................__...-._..................... FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451 a-c. VII. UNDER DISPENSER CONTAINMENT(UDC} CONSTRUCTION TYPE ® I.SINGLE WALL ® 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a ...................................................._........._.................................................................................................................................................._........._..__._....._.._...._............................................................_...........---...............................................................-..................... CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696: VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that is U T system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and i full mpgance With legal requirements. APPLICANT SIGNATURE: DATE 06/11/2009 470 APPLICANT NAME(print) Chevron Pr d ils Co./JIM HARTMAN 471. APPLICANT TITLE Retail HES Permit Desk 472. UPCF UST-B Rev.(12/2007)