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FIED PROGRAM CONSOLIDATED F 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) i .� _(„ 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. L FACILITY INFORMATION FACILITY ID # (Agency Use Only) I-1010101=1 !51 C 1> �3. BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 7 -Eleven # 20632 BUSINESS SITE ADDRESS 103. CITY 104. 4627 DaVinci Dr. 1 Stockton II. TANK DESCRIPTION .. .... c- c _ 432. TANK ID # -�� ? ) 3 ��. TANK MANUFACTURER 433. TANK CONFIGURATION: THIS TANK IS 434. 002 Total Containment ® L 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. 4/1998 10,000 M. TANK USE AND CONTENTS , TANK USE ® la. 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 ❑ 99. OTHER (Specify): 439a. ................................................................................_.._..........._....__.._.._.._......----.._......_..............................__..._...................................._........................................................._............................................ -...._.............. ........ _........ _..........._.......... CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ® Ib. 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..1ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 440b. 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 [13. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ® 7. JACKETED 445. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 4 4 5a. OVERFILL PREVENTION ® 1. AUDIBLE &VISUAL ALARMS ❑ 2. BALL FLOAT ® 3. FILL TUBE SHUT-OFF VALVE 452• ❑ 4. TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUe / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1 SINGLE WALL ® 2. DOUBLE WALL ❑ 99. OTHER 460. ...................._..._....................................._..._................_......_.........._...._...-....... --._.._.._.._...._......... .............................................................. ......-.............. ---......................................................_......_........................................................................................................................................................... SYSTEM TYPE ® L PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION [__14. SAFE SUCTION [23 CCR §2636(a)(3)] 458. - ..... ...... .............. ................ ❑.....10. RIGID PLASTIC.............. .......... PRIMARY CONTAINMENT 111. STEEL ............ .....................................................464. .❑ 4. FIBERGLASS .....................0-9" . FLEXIBLE---._ -------------- ❑ 90. NONE_ ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464a. ....._............................................................... SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ® 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b. ❑..._90.:._ NONE UNKNOWN OTHER (Specify): 464c. .... ...........................❑..._95.:._ ............_....._._❑..._99:. - PIPING/ riJRBINE CONTAINMENT SUMP TYPE ®1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4644. VI. VENT, VAPOR RECOVERY (VR) AND RISER /FILL PIPE PIPING CONSTRUCTION' VENT PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS [110. RIGID PLASTIC [390. NONE [199. OTHER (Specify): 4W' ............................... ................. .......................................................... ......................_......... _... _..---........................... ....... ---._....... ----........._....._.._....................... _............. ........................................................................................................................................................ _. _._......... VENT SECONDARY CONTAINMENT ❑ 1. STEEL [14. FIBERGLASS [110. RIGID PLASTIC ® 90. NONE [199. OTHER (S cif ): 464C ......................._........................................................ _.-..... ---............... _................................................................................................................._�......_y..... .464f1.... VR PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ ]0. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER . (Specify): .46a4� _................_...__............................................................................................................................_.... ...................................__.__.............................._...........____......................_.................._...._................................................................................................................................................................. &....... VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 464h. ...._...................................................................................................................................................._. 464hl . .....................................-_....._..................._.................................................................................................._..........................._._..........................__......................_.................................................... ...............� .., VENT PIPING TRANSITION SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464'. .......... ................................................................................................................................................................................................... .................................................................................... _.................................... _........... .................... _............................ ............. ................................................................................................................................................. RISER PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specif ): 4641' ... ---....... _............................................. .....-...................................................................................... _.......... _.............................. __.._._.__............ _............................................................................................................................................. ........... ................................................ .._.............................................._y...... 464 1. RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 46441 ................:... FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45ta-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ®1 SINGLE WALL ❑ 2 DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90 [NE 469a ...............................__.............................. ............. ........ ......... _......_ ......... CONSTRUCTION MATERIAL ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469c 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 profidedt. herein is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATE �Z /3, �o p r 470• APPLICANT NAME (print) Ian Moorhead 471. APPLICANT/ TITLE Env. Compliance Mgr. 472' UPCF UST -11 Rev. (1212007) - 1/2 www.unidocs.org