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<br />UPCF UST -I3 -1/2 Rev. (12/2007)
<br />UNIFIED PROGRAM CONSOLIDATED FORM
<br />UNDERGROUND STORAGE TANK
<br />OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST)
<br />TYPE OF ACTION (Check one [tem only, For an UST permanent closure or removal, complete only this section and Sections 1, 11, 111, IV, and IX below)
<br />430
<br />® 1, NEW PERMIT ❑ 3, RENEWAL PERMIT ❑ 5; CHANGE OF INFORMATION
<br />❑ 6, TEMPORARY UST CLOSURE ❑ 7, UST PERMANENT CLOSURE ON SITE ❑ 8, UST REMOVAL.
<br />DATE UST PERMANENTLY CLOSED: 430a
<br />DATE EXISTING UST DISCOVERED:
<br />430b
<br />I, FACILITY INFORMATION
<br />FACILITY ID # (Agency Use Only)
<br />_
<br />I
<br />BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As)
<br />3
<br />7�Eleven, Inc
<br />BUSINESS SITE ADDRE�S S 103 CITY
<br />Al kA S f Stockton
<br />104
<br />1�y I6 i F9 "Y?
<br />1I. TANK DESCRIPTION
<br />TANK ID #432
<br />TANK MANUFACTURER 433
<br />TANK CONFIGURATION: THIS TANK IS
<br />434
<br />El I,A STAND-ALONE
<br />i��S
<br />NEINACOMPARTMENTED UNIT .
<br />om Icteenc a e for each com artment in the unit.
<br />DATE UST SYSTEM INSTALLED 435
<br />TANKPA Pfd j GALLONS 436
<br />NU ITER OF COMPARTMENTS IN THE UNIT
<br />437
<br />(J(J
<br />III, TANK USE AND CONTENTS
<br />TANK USE I n, MOTOR VEHICLE FUELING ❑ 1b. MARINA FUELING ❑ ic. AVIATION FUELING
<br />439
<br />3, CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used oil) ❑ 5, EMERGENCY GENERATOR FUEL [HSC §25281.5(c)]
<br />❑ 6, OTHER GENERATOR FUEL ❑ 95, UNKNOWN ❑ 99, OTHER (Specify):
<br />439a
<br />CONTENTS PETROLEUM: [Ila, REGULAILUNLEADED ❑ let MIDGRADE UNLEADED El 16 PREMIUM UNLEADED;, ,-
<br />440
<br />3; DIESEL ✓✓ [:15, JET FUEL El 6, AVIATION
<br />8, PETROLEUM BLEND FUEL ❑ 9, OTHER PETROLEUM ; (S eo y
<br />440a
<br />NON -PETROLEUM: ❑ 7, USED OIL ❑ 10, ETHANOL
<br />❑ 1 L OTHER NON -PETROLEUM (Specify):
<br />440b
<br />IV. TANK CONSTRUCTION I) j6'/
<br />TYPE OF TANK ❑ 1. SINGLE WALL DJC2. DOUBLE WALL ❑ 95. UNKNOWN J r,.t
<br />443
<br />PRIMARY CONTAINMENT ❑ 1, STEEL J213, FIBERGLASS ❑ G. INTERNAL BLADDER
<br />444
<br />❑ 74 STEEL+ INTERNAL LINING [195, UNKNOWN El 999 OTHER (Specify):- ,t q(a�
<br />444a
<br />SECONDARY CONTAINMENT ❑ L STEEL 3k3, FIBERGLASS ❑ G, EXTERIOR MEMBRANE LI ERVn i' •gp; jA.QKE7 EDS &
<br />445
<br />❑ 90, NONE [195, UNKNOWN ❑99.OTHER (Specify): 94�`�`'" �,r.r;i!`.1\t°
<br />445a
<br />OVERFILL PREVENTION 1, AUDIBLE & VISUAL ALARMS ❑ 2, BALL FLOAT 3, FILL TUBE 41l.UT;OFF�VALVE
<br />4520
<br />❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT
<br />V. PRODUCT / WASTE PIPING CONSTRUCTION '
<br />PIPING CONSTRUCTION ❑ I, SINGLE -WALLED , DOUBLE -WALLED ❑ 99, OTHER
<br />460
<br />SYSTEM TYPE 1, PRESSURE ❑ 2. GRAVITY ❑ 3, CONVENTIONAL SUCTION ❑ 4, SAFE SUCTION [23 CCR §206(a)(3)]
<br />458
<br />PRIMARY CONTAINMENT ❑ I, STEEL K4a FIBERGLASS ❑ 8, FLEXIBLE ❑ 10, RIGID PLASTIC
<br />464
<br />❑ 90, NONE ❑ 95. UNKNOWN ❑ 99, OTHER(Specify):
<br />464a
<br />SECONDARY CONTAINMENT ❑ I, STEEL 4, FIBERGLASS ❑ 8. FLEXIBLE ❑ 10, RIGID PLASTIC
<br />464b
<br />❑ 90, NONE ❑ 95, UNKNOWN ❑ 99. OTHER (Specify):
<br />464c
<br />PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ L SINGLE WALL 2, DOUBLE WALL
<br />❑ 904 NONE
<br />4644
<br />VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION
<br />VENT PRIMARY CONTAINMENT ❑ I, STEEL 4. FIBERGLASS ❑ 10, RIGID PLASTIC ❑ 90, NONE ❑ 99, OTHER (Specify)
<br />464e
<br />464ei
<br />VENT SECONDARY CONTAINMENT ❑ 14 STEEL wX4. FIBERGLASS ❑ 10, RIGID PLASTIC ❑ 90, NONE ❑ 99. OTHER (Specify)
<br />4641'
<br />464fi
<br />VR PRIMARY CONTAINMENT ElI. STEEL 4, FIBERGLASS El10, RIGID PLASTIC X9Ot NONE ❑ 99, OTHER (Specify)
<br />4641;
<br />464 •1
<br />VR SECONDARY CONTAINMENT ❑ 1, STEEL 1, FIBERGLASS ❑ 10, RIGID PLASTIC 90, NONE. ❑ 99, OTHER (Specify)
<br />464h
<br />4601
<br />VENT PIPING TRANSITION SUMP TYPE ❑ L SINGLE WAI"t_ 7%2, DOUBLE WALL ❑ 90, NONE
<br />4641.
<br />RISER PRIMARY CONTAINMENT At, STEEL it FIBERGLASS ❑ 10, RIGID PLASTIC ❑ 90, NONE ❑ 99, OTHER (Specify)
<br />84464
<br />RISER SECONDARY CONTAINMENT El Is STEEL 4, FIBEROLASS ❑ 10. RIGID PLASTIC ❑ 90, NONE ❑ 99, OTHER (Specify)
<br />4641:
<br />4G4k1
<br />FILL
<br />COMPONENTS INSTALLED
<br />2klaSPILLBUCKET
<br />K,3, STRIKER PLATE/BOTTOM PROTECTOR 4. CONTAINMENT SUMP
<br />451o•c.
<br />VII, UNDER DISPENSER CONTAINMENT (UDC)
<br />CONSTRUCTION TYPE ❑ I, SINGLE WALL 2. DOUBLE WALL ❑ 3, NO DISPENSERS ❑ 90, NONE
<br />469a
<br />CONSTRUCTION MATERIAL ❑ L STEEL FIBERGLASS ❑ 10, RIGID PLASTIC ❑ 99, OTHER (Specify)
<br />469b -c.
<br />VIII. CORROSION PROTECTION
<br />STEEL COMPONENT PROTECTION ❑ 2, SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT 6, ISOLATION
<br />448'
<br />IX. APPLICANT SIGNATURE
<br />CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,
<br />accurate,
<br />and in fall coo Mance with legal requirements.
<br />APPLICANT SIGNATURE
<br />DATE
<br />470'
<br />APPLICANT NAME (print)J000,11e4r1.
<br />APPLICANT TITLE
<br />472'
<br />UPCF UST -I3 -1/2 Rev. (12/2007)
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