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.. '_w4 / Ask MEL FIED 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,A 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: 430x. 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#96171 BUSINESS SITE ADDRESS 103, CITY 104. 6633 Pacific Ave Stockton, CA 95207 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434. 3 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. 01/01/1986 10,000 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: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ® 1b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8_PETROLEUM BLEND FUEL............_[1 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.UNKNOWN443. ............................................_.._............................_.............................................................................................._....................................._......_.-..._................._..._............................................................................................... PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444x. ...................................................__............................................................................... ---............................. ........................................................................................... ................................................... 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 19 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(ax3)] 458. _..........................................................:. .................... PRIMARY CONTAINMENT ❑ 1.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 4646. ❑ 90.NONE _ ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. _._..................................... ..................................................... PIPING/TURBINE 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 ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46aei. .............................-_.................................................._.......................................__........................._.._..-_...__........................_....._....................................._...................---.................................................................................................................................__._._..._...---..._............ .....464E..... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464£1 ......_.........._.._..__._._...._..........................__...................................._..._...._.................................................................................-._.._..- -.._........................ ........................................................................._................---.._.._........._.......... _................_... .._.__._ VR PRIMARY CONTAINMENT [1 [1 [1El464g. 1.STEEL ® 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify): 8464 ---...._.................................................................................................................................--.......----_........................_.._._._............................................................................................................................._.......................... VR SECONDARY CONTAINMENT [:11.STEEL [14.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): g64hl . . ......._..----.......................... .__._... --...................................................................................................................................__..................._.__._....._.................................................._.._.......................................................................................................................................... ..... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE ...................................................__ ................................._........................_._......_............................................_........................_.................._....__.............................._.................................................................................................................................................... RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46441, ............................................................................_......................._..._._..................................................._............._.......---'---..................._...__...._................................_.....................................................................................................__.......................__.._........... ..---..__............................_..... RISER SECONDARY CONTAINMENT ❑ 1.STEEL El4.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 45la-c. VII. UNDER DISPENSER CONTAINMENT (UPC) CONSTRUCTION TYPE ® 1.SINGLE WALL [:12.DOUBLE WALL [13.NO DISPENSERS ❑ 9 . ONE 469a. .......................... .......__....................._.............................................................................................................................. ............. CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHERS OTHER(Specify) ( P fY) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATIO °j' 448. IX. APPLICANT SIGNATURE ' ' CERTIFICATION: I certify that th' UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in m liance with legal requirements. APPLICANT SIGNATURE: DATE 06/10/2009 470 APPLICANT NAME(print) Chevron Pr d Co./JIM HARTMAN 471. APPLICANT TITLE Retail HES Pe a. Desk 472 UPCF UST-B Rev.(12/2007)