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I �P �.i UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only, For an UST permanent closure or removal, complete only this section and Sections], 11, III, IV, and IX below) 430 ® I. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5: CI-IANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7, UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 43ob I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ _ I BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 7"Eleven, Inc 103 StITY BUSINESS SITE ADDREPS S,1 ockton too 1�Y / ' II. TANK DESCRIPTION TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ❑ I. A STAND-ALONE TANK &2. ONE INA COMPARTMENTED UNIT. Com tete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY( IN GALLONS 436 NUMBER OF COMPARTMENTS 1N THE UNIT 437 12,1 III. TANK USE AND CONTENTS TANK USE In. 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)I E1.69 OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99, OTHER (Specify): 439a CONTENTS PETROLEUM: Ella, REGULAR UNLEADED ElIc, MIDGRADE UNLEADED Ib. PREMIUM UNLEADED;r - I', 440 El 3; DIESEL ❑ 5, JET FUEL ❑ G AVIATIGN GAS ❑ 8, PETROLEUM BLEND FUEL❑ 96 OTHER PETROLEUM : (S ecif 440° NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL =_ ❑ 11, OTHER NON -PETROLEUM (Specify): 44ob IV. TANI{ CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL 18Cg4DOUBLE WALL ❑ 95. UNKNOWN PRIMARY CONTAINMENT ❑ 1. STEEL 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 444a ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify):- ,�-;a : SECONDARY CONTAINMENT ❑ I. STEEL X3, FIBERGLASS ❑ 6, EXTERIOR MEMBRANE LIj�EI { 1 CFXET86Q_ -r, 445 [1 90, NONE ❑ 95. UNKNOWN ❑ 99.OTHER (Specify): 1 a , i� _ > r ��"I,a 445a OVERFILL PREVENTION _�K 1. AUDIBLE Rc VISUAL ALARMS ❑ 2. BALL FLOAT 3, FILL TUBE MUT OFF VALVE _ 4520 Ky El 4, TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION' PIPING CONSTRUCTION ❑ L SINGLE -WALLED , DOUBLE -WALLED ❑ 994 OTHER 460 SYSTEM TYPE 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(x)(3)] 458 PRIMARY CONTAINMENT ❑ I. STEEL 4. FIBERGLASS El8. FLEXIBLE ❑ 10. RIGID PLASTIC 454 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I. STEEL 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90, NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL 2. DOUBLE WALL ❑ 90, NONE 4644 VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I, STEEL 4. FIBERGLASS ❑ 10, RIGID PLASTIC ❑ 90, NONE ❑ 99, OTHER (Specify) 464c 46acl VENT SECONDARY CONTAINMENT ❑ 1. STEEL X4, FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99v OTHER (Specify) 464f 464N VR PRIMARY CONTAINMENT ❑ 1. STEEL 4, FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99a OTHER (Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ I, STEEL 4. FIBERGLASS ❑ 10, RIGID PLASTIC ❑ 90. NONE. ❑ 990 OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WA1 _r. , DOUBLE WALL ❑ 90. NONE 464i. RISER PRIMARY CONTAINMENT 1, STEEL k. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 904 NONE ❑ 99, OTHER (Specify) 4641 a6ai i RISER SECONDARY CONTAINMENT ❑ 1. STEEL 4, FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90, NONE ❑ 99, OTHER (Specify) 464k 4641:1 FILL COMPONENTS INSTALLED XI.SPILLBUCKHT K,3, STRIKER PLATE/BOTTOM PROTECTOR 4. CONTAINMENT SUMP 4510-c VII, UNDER DISPENSER CONTAINMENT (URIC) CONSTRUCTION TYPE ❑ L SINGLE WALL 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ .90. NONE 469a CONSTRUCTION MATERIAL ❑ 1. STEEL FIBERGLASS ❑ l0. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b -c 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 provided herein is true, accurate, and in full compliance with legal requirements, APPLICANT SIGNATURE DATE 470' Ol APPLICANT NAME (print) 471. APPLICANT TITLE 472' UPCF UST -R -1/2 Itcv. (12/2007)