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AddL IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE F 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 ❑ L 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: 4306. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Chevron Station#209167 BUSINESS SITE ADDRESS 103.7ITY 104. 1234 Yosemite Ave I Manteca, CA 95336 Ii. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434• 2 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 15,000 0 III. TANK USE AND CONTENTS TANK USE ® Ia.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)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN [:199.OTHER(Specify): 439a. .............. ....................... CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _........................................................................_ ..._8:._PETROLEUM.BLEND FUEL._........._El 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 [195.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING [195.UNKNOWN [199.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[23 CCR§2636(a)(3)] 458. ............ ............................................_.._................................................................................... ........................................................................_._.._.-.............. . PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWNEl99.OTHER(Specify): 464a. -.....-...._.............................................................................................................................. ...._.............................. ............... SECONDARY CONTAINMENT ❑ 1.ST -EEL ® 4.FIBERGLASS El 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. ---.._.._.............................................._......................................................................................................._.__._..._.__.........................................................._..............---............................. .................I.........._...__.__.._. 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 ® L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g64ej _.......................................-----................................................................................................................ .........................................................................................................................---............................_.._................................................................................-.......................... ............. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): q4 flf ..........................................................................................................--._..........................................__.........._........._...._..-._.._...---...._........................................................................................................................._-._................-._.._....................._._..................................._... ....4 ......... VR PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS [__110.RIGID PLASTIC ❑ 90.NONE El 99.OTHER(Specify): . .. . . . ............................. 464 B ..................................................-----...__.................._._..._....................................._. . . . _................................_.._.................................................................................................................................__ ..---......................._....................................................................................... 8..-. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): q�I ._....._...._........_.._..................-.........................................................................................................................................._..-_._.........._.._.-.__............_......................................._........................_......._.................................................................................................................................................. 4 _-.. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE _ .. ................ RISER PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90. ONE 99.OTHER(Specify): 464j. .................................................-..__...._..................... ... RISER SECONDARY CONTAINMENT [11.STEEL [14.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE [14644.99.OTHER(Specify): 46441. _.. .................................................................................................................................................................._................................................................................._....................................................................................................................................................................................................................................................... FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451 a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. ......... .. .................... ................ ..... .................................................. . ........................ .............. ..........................._......................................... ........ 696. .. 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. M APPLICANT SIGNATURE CERTIFICATION: I certify that thisST s stem is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in futcomlWance with legal requirements. APPLICANT SIGNATURE: DATE 06/11/2009 470 APPLICANT NAME(print) Chevron Prd.�sVo./JIM HARTMAN 471. APPLICANT TITLE Retail HES Permit Desk 472 UPCF UST-B Rev.(12/2007)