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<br />UPCF UST -B 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 item only. For a UST closure or removal, complete only this section and Sections I, 11, 111, IV, and IX below)
<br />Oso.
<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: 430x. I DATE EXISTING UST DISCOVERED:
<br />430b.
<br />I. FACILITY INFORMATION
<br />FACILITY ID # (Agency Use Only) _
<br />1
<br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As)
<br />3.
<br />Chevron Station# 307709
<br />BUSINESS SITE ADDRESS 103
<br />CITY
<br />104.
<br />10858 Trinity Parkway
<br />1 Stockton, CA 95219
<br />II. TANK DESCRIPTION
<br />TANK ID #rA b I 432
<br />TANK MANUFACTURER 433.
<br />TANK CONFIGURATION: THIS TANK IS
<br />434.
<br />XERXES
<br />® 1. A STAND-ALONE TANK Complete one page for each
<br />❑ 2. ONE IN A COMPARTMENTED UNIT compartment in the unit.
<br />DATE UST SYSTEM INSTALLED 435.
<br />TANK CAPACITY IN GALLONS 436.
<br />NUMBER OF COMPARTMENTS IN THE UNIT
<br />437.
<br />07/01/2006
<br />20,000
<br />III. TANK USE AND CONTENTS
<br />TANK USE ® la. MOTOR VEHICLE FUELING ❑ 1b. MARINA FUELING ❑ le. AVIATION FUELING 439.
<br />❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)]
<br />_
<br />_ ____ _❑_ 6. _OTHER GENERATOR FUEL _ _ ❑ _95_. UNKNOWN _ _ ❑ 99.OTHER S eci
<br />V❑
<br />439&
<br />_
<br />CONTENTS PETROLEUM: ® la. REGULAR UNLEADED lc. MIDGRADE UNLEADED - ❑ Ib. PREMI MPUNLEADED» �- M M
<br />440.
<br />❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS
<br />_.�0_ 8. PETROLEUM BLEND ❑ 9. OTHER PETROLEUM (Specify): 440a.
<br />.._.
<br />_ _ _ -__..._-
<br />NO N -PETROLEUM: 7. USED OIL ❑ 10. ETHANOL
<br />❑ 11. OTHER NON -PETROLEUM (Specify): 440b.
<br />IV. TANK CONSTRUCTION
<br />TYPE OF TANK ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 95. UNKNOWN
<br />_._._.._...-'-''-.._._.__... ,.»....._._........_...,._......_.__..........._.._._.-__......_.__............_........_...._._
<br />443.
<br />..............-....-..............._._........__.-.._._.........................._.__.................._........................._...._........._._..................._...._................................._..............._.............._..._....._....
<br />PRIMARY CONTAINMENT ❑ 1. STEEL ® 3. FIBERGLASS ❑ 6. INTERNAL BLADDER
<br />444.
<br />__....._.»..._,....,......_._,..................... _........_?:.STEEL +..INTERNAL LINING.-. _ . ._.. _.......»❑... 95. UNKNOWN.._ �...._»......_..........._
<br />444a.
<br />._❑...99.OTHER_CSPeci
<br />SECONDARY CONTAINMENT ❑ I. STEEL ® 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED - _
<br />445.
<br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445a.
<br />VERFILL PREVENTION ® 1. AUDIBLE &VISUAL ALARMS ® 2. BALL FLOAT [13. FILL TUBE SHUT-OFF VALVE
<br />452.
<br />❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT
<br />V. PRODUCT / WASTE PIPING CONSTRUCTION
<br />PIPING CONSTRUCTION ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 99. OTHER (SPecify), 460.
<br />-_........-..._..._»_..._...».».._...,_........_..._......._..»_.._.........».,..._.....»...,.-.....,........»..........................»._...........,...,...._............. ..... ..... ..........,....
<br />.... .._..... ...._....,....................
<br />SYSTEM »TYPE _ ® 1. PRESSURE -.........J...- ❑mm2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a.....
<br />............ ......_._.._._.._......,..._..
<br />458.
<br />_......__...__.._........._..._.._...,__._...�..... -.._._.,..,.__._.
<br />PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC
<br />464.
<br />090. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464a
<br />__..._.. __.._. .__._,.-...._,._..�._...... , -'-- »....._»_......_.......__._
<br />......._......__.._.._......---....._........__..._.._..._..._
<br />SECONDARY CONTAINMENT ❑ I. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC
<br />464b.
<br />❑ 90, NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c.
<br />_...........».,..._...».._......_.....,....__...._,_..........,........_..................._...__......................................
<br />_,........._._.__.............._._...................._.__......................__._......... ..._............,_... __
<br />PIP[NG/TURBINE CONTAI NMENT SUMP TYPE ❑ ). SINGLE WALL ® 2. DOUBLE WALL ❑ 90. NONE _
<br />464d
<br />VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTIO N
<br />VENT PRIMARY CONTAINMENT ❑ LSTEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify):
<br />_._._.._,_......__..._...__._..-.._..__..._.__.....,.._...._-___......_._._...._....._.
<br />464e.
<br />................_._..____......._,._,._....._.__._..-.._..-.._..........._.._.._. _...
<br />VENT SECONDARY CONTAINMENT ❑ L STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify):
<br />464e 1.
<br />464f
<br />..._....__....,..__,_......_.._.
<br />VR PRIMARY CONTAINMENT El 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE [199.OTHER (Specify):
<br />464£1.
<br />464g.
<br />VR SECONDARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify):
<br />464g].
<br />464h.
<br />VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 90. NONE
<br />_._..._. __-_ _ ».__._._. _,.........__... -'-'--....»._.._»._.._......._....,_._»._.,._,...
<br />464h1.
<br />464i.
<br />_ ......,._......._._..,......_.._._.._.._.,...,......._..._.»._.__._........ .._.... ..._._...................... _._.......... .............. ...... ..... _.._•-•»._........_._......
<br />RISER PRIMARY CONTAINMENT ❑ I. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE [199.OTHER (Specify):
<br />........................_�............_...._......................................._.........................................._.....
<br />46a4i.
<br />RISER SECONDARY CONTA INMENT ❑ 1. STEEL ® 4. FIBERGLASS [110. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify):
<br />464 .
<br />464k 1.
<br />FILL COMPONENTS INSTA LLED ® I. SPILL BUCKET ® 3. STRIKER PLATE/BOT rom PROTECTOR ® 4. CONTAINMENT SUMP
<br />45la-c.
<br />VII. UNDER DISPENSER CONTAINMENT (UDC)
<br />CONSTRUCTION TYPE ❑ I SINGLE WALL ® 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE
<br />- --......................,_... ..._.»...._._....__._.......__............__..._....._-•--._,......._...... _.._._...._.._...................... -.........._._..._.._.........................................._................_...._............................_...._................................_..._........__..._.........................
<br />469&
<br />........... ......... ........ .......
<br />CONSTRUCTION MATERIAL ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (S eci
<br />P �)
<br />...... _.....-
<br />469b.
<br />469c.
<br />VIII. CORROSION PROTECTION
<br />STEEL COMPONENT PROTE CTION ❑ 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, and in full compliance with legal re uirements.
<br />APPLICANT SIGNATURE:���' ' --<'-''�
<br />DATE 04/29/2011
<br />470.
<br />F
<br />APPLIC ANT NAME (print) Chevron Products Co./ Charles Bittle 471
<br />APPLICANT TITLE Chevron Retail HES Pen -nit D
<br />472
<br />UPCF UST -B Rev. (12/2007)'
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