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Ask b FIED PROGRAM CONSOLIDATED FO. ee 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 1,,//,111 /V,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) T0 0 10 __ SC t• BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) V 3. 7-Eleven#32262 BUSINESS SITE ADDRESS 103. CITY 104. 2360 W. Grant Line Rd. Trac IU TANK DESCRIPTION TANK ID# �� /_g 432• TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 002 ((� 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. 6/2003 10,000 III'. 'TANKE 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)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. ......................................................................................................................................................................................................................................................................................................................................................................................................................... ....................... CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ® lc.MIDGRADE UNLEADED ❑ lb.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(S ecif ): 440b. CQNSTRUCTION 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 E UIPMENT V. PRODUCT/WASTE:PIPING CONST OTI(� PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL [199.OTHER 460. ................................................................................................................................................................................................................................................................................................................................................................................. SYSTEM TYPE ® L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458• PRIMARY CONTAMENT ❑ 1.STEEL �4.FIBERGLASS V 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. IN ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. ......................................................................................................................................................................................................................................................... ....................................................... SECONDARY CONTAINMENT ❑ 1.STEEL X4.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 a64d. 'PENT,V'' ._OR RECOVERY(VR)Al'1D'RISER/FILE PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q ....................... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464t ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .... .... [1 [1 [:1 [34� ..... VR PRIMARY CONTAINMENT 1.STEEL ® 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify): 464 j ..................................................................................................................................................................................................................................................................................._......................................................................................................................................................................................................................... &.......... VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a6ah1. ................................................................................................................................................................................................................................................ ...................................................................................................................................................................................................................._............. .................. VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464t ..................................1......... ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................... RISER PRIMARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q46 j: ......................................... ................................................................................................ ................................. ......................................................... ................................................................... ............................. .................................................................. 1.......... RISER SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g464 ................:...... .................................................................................................................................................................................._......_............................................................................................................................................................................................................................................................................................................... 451 a-c. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP VII. ,LEER DISPENSER CONTA TMET(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90 NON 469a. .......... .... ................................................... .... ... ........ ..... ....... ..... ...... .... .. ..... ......... .................... . ............-................................ ......... .. CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b. 469c, VIII. CORROSION PRG�'IO� -- STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. a` i' P"PLIC T SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided KVM is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE -:21-_, 119 ' � - DATE /a F 470. APPLICANT NAME(print) Ian Moorhead 471' APPLICANT TITLE Env. Compliance Mgr. UZI q72' UPCF UST-B Rev.(1212007)-1/2 www.unidocs.org