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bl lam' {Zll 1 L IED PROGRAM CONSOLIDATED JFOFMW 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. 1 DATE EXISTING UST DISCOVERED: 4306, I. FACILITY INFORM- ION FACILITY ID#(Agency Use Only) _ 1-1-310 '� I. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 Chevron Station#208117 BUSINESS SITE ADDRESS 103 CITY 104, 755 S. Tracy Blvd Tracy , CA 95376 II. TANK DESCRIPTION TANK ID#f i �C , 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. 09/01/1998 20,000 0 III. 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 ❑ lb.PREMUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _.................................._.........................._............. ._._.__._ ..._8 PETROLEUM BLEND FUEL.........._ ..... OTHER PETROLEUM..(S��'.fY)):...... 4aoa. .._...._.......---._... NON-PETROLEUM:❑ .1. 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 0 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 ............ ......................... ................................................................ SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY [1 3.CONVENTIONAL SUCTION [:14.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): 464a. .........._..........................._........................................--.........................._.....................................__._........................................................................ ....................................................... 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 ® LS I N G L E WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENTPRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99..OTHER(Specify): aa4ae..................................... ............. ....... ............................................................................................................................................................ ............................. .......... ........... ............................................................................................................... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4564£ .._................. ..............................................................._.........._........................................................................._.............................._............................_............................................................................................................................................_......_......._......................... VR PRIMARY CONTAINMENT [11.STEEL ® 4.FIBERGLASS [:110.RIGID PLASTIC [190.NONE [1464 .99.OTHER(Specify): 464gg. ........................................................_..............................................._........._.._...........__.........._.........._......................................................................................................................................_........................................._..........................----._...._............................_...._._..._............................................... VR SECONDARY CONTAINMENT [:11.STEEL [:14.FIBERGLASS [I10.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): 464h1. ---- VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL [12.DOUBLE WALL ® 90.NONE ....__........................._._-........................................_.........................................................................................................._......................._.._._......................_........................................................_............._............................................. . RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): a464j .................................................._.__........................-..........__......_......._...........----'-...........__..........._............._................................................................................................................................................._......................................_.._...._....................___.............................._........................................ 464k. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464k1. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTT0M PROTECTOR ® 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.N 469a. .........................................................-..._..................................................................._...._..._......._.._........_....._................._.._..................................................................................................................................._..... ............................................... CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) VIII. CORROSION PROTECTION v ^' STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.HAPRESSED CURRENT ❑ 6.ISOLATION -3=:w 448. M APPLICANT SIGNATURE fe-3 CERTIFICATION: I certify that s ST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and n fullicompliance with legal requirements. APPLICANT SIGNATURE: DATE 06/12/2009 470 APPLICANT NAME(print) Chevro ucts Co./JIM HARTMAN 471 APPLICANT TITLE Retail HES Permit Desk 472 UPCF UST-B Rev.(12/2007)