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Milk FIED PROGRAM CONSOLIDATED FOMW 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 111,111,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 INFO ION FACILITY ID#(Agency Use Only) _ BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Chevron Station #208117 BUSINESS SITE ADDRESS 103. 1 CITY 104. 755 S. Tracy Blvd Tracy , CA 95376 II. TANK DESCRIPTION TANK ID g //� 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. '} G7! 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 15,000 0 III. TANK USE AND CONTENTS TANK USE ® 1 a.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 ® 1b.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8 PETROLEUM BLEND 0 9.OTHER PETROLEUM(Specify): 440a. .............................................................................. ........ ............................................. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 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 ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. OVERFILL PREVENTION ® .L ADL RM ❑ ® 452. UIBLE&VISUAALAS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE ❑ 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 ® L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. ..........................................................................................................................................................................................................._.................-.........._.............................. .................... . PRIMARY CONTAINMENT ❑ L 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): 464e1. ........................................_.................................---............................................_..........._....................................... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 45 4f. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464g. ......__...........-----......._.............................._..._...__.............................._..............................................................................................................................................._....................._................................................................................................................................._................-......................_.........._..._ _.....6.......... VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): g464. ...................... .............................................................................................................._................................................................................................................................_..........................................................................................................__......._................_...._................__........................._.__...............VENT PIPING TRANSITION SUMP TYPE [11.SINGLE WALL [12.DOUBLE WALL ® 90.NONE464i. ................................................... ........ .............._.._..:........---............_..._..................................................................................................................................................._........................_...........-......._..................._................................................................................................................................ ................. RISER PRIMARY CONTAINMENT ® 1.STEEL El 4.FIBERGLASS [110.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify): q:i . .......... .........................__........._......_.............----.........._..............._.............._..............................................................................................................................._.............--.._.._.........................-..................................._..._......................................................._.............................._................... J.__. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 8464. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/B0TTOM PROTECTOR ® 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® t.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.N 469a. ..........................................__...-_................_._.._...................._..............................._.._..........................................................................................................._.............__................._-._.................._......._-................................................................................................................................................ .. .........................__........_ CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) Z'.-' 4696' ..,.r 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.RAPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify t at tht UST system is compatible with the hazardous substance stored and that the information provid herein is true, accurate,a din f 11 compliance with legal requirements. APPLICANT SIGNATURE: DATE 06/12/2009 470 APPLICANT NAME(print) Chev n r nets Co./JIM HARTMAN 471. APPLICANT TITLE Retail HES Permit Desk 472 UPCF UST-11 Rev.(12/2007) C�