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- a -Aiii� <r �:)
<br />UNIFIED PROGRAM CONSOLIDATED FORM
<br />UNDERGROUND STORAGE TANK na cQ t
<br />OPERATING PERMIT APPLICATION - TANK INFORMATION (o for per UST)
<br />TYPE OF ACTION (Check one item only. For a UST closure or removal, complete only this section and Sections I, A III, IV, and IX below) 430
<br />❑ I. NEW PERMIT ® 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION
<br />❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL
<br />r)A TG' 1ICT DUDA.A wrr- „.., 1.... _
<br />FACILITY ID # (Agency Use Only) I. FACILITY INFORMATION
<br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As)
<br />Chevron Station# 307709
<br />3
<br />BUSINESS SITE ADDRESS 103,
<br />CITY
<br />10858 Trinity Parkway
<br />Stockton, CA 95219
<br />104.
<br />II. TANK DESCRIPTION
<br />TANK ID # ( a3433.TANK
<br />TANK MANUFACTURER
<br />CONFIGURATION: THIS TANK IS
<br />434.
<br />--�-�
<br />XERXES
<br />❑ 1. A STAND-ALONE TANK Complete one page for each
<br />S 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 />12,000
<br />1 of 2
<br />III. TANK USE AND CONTENTS
<br />TANK USE ® la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ Ic. AVIATION FUELING 439.
<br />❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c))
<br />_,-______ ..... ___Q 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99.OTHERjSpecif�);
<br />_ __...._.. _. ._... ___, ».
<br />CONTENTS
<br />439a.
<br />._ .
<br />PETROLEUM: ❑ la. REGULAR UNLEADED """""'" """"'"""" """'
<br />❑ 3. DIESEL ❑ Ic. MIDGRADE UNLEADED ® Ib. PREMIUM UNLEADED
<br />440.
<br />❑ 5. JET FUEL ❑ 6. AVIATION GAS
<br />❑ 8. PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440&
<br />_.....,._...,......,..._....,.__...,�_,..,....»...___......._..,....__._._.._._.,_......-.,.__.._................_..._..
<br />..._ ._._._.. _ ._. _.._�..
<br />NO N -PETROLEUM: 7. USED OIL
<br />❑ It. OTHER NON -PETROLEUM (Specify): 4406.
<br />IV. TANK CONSTRUCTION
<br />TYPE OF TANK ❑ I SINGLE WALL ® 2. DOUBLE WALL ❑ 95. UNKNOWN
<br />443,
<br />_
<br />PRIMARYCONTAINMEN........_.__. ..................... _ .......... ................. ................................ _.............................. ................................... ........ .._.__..._............
<br />T ❑ 1. STEEL ® 3. FIBERGLASS ❑ 6. INTERNAL BLADDER
<br />444.
<br />❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify),
<br />444a.
<br />SECONDARY CONTAINMENT ❑ 1. STEEL S 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED
<br />445.
<br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER (Specify): 445a.
<br />_.......,...__._._._....,..._..._...._............._._.................................»....._............_.................._....................__.............._......_................._.._..._.,............_._.......,..................................._..........................
<br />OVERFILL PREVENTION ®1. AUDIBLE & VISUAL ALARMS S 2. BALL FLOAT C33. FILL TUBE SHUT-OFF VALVE _ T
<br />452.
<br />C3 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT
<br />V. PRODUCT / WASTE PIPING CONSTRUCTION
<br />PIPING CONSTRUCTION ❑ 1 SINGLE WALL S 2. DOUBLE WALL ❑ 99.OTHER S eci 460.
<br />»,........._,.................__._..............._...»............,........................................,...........,.,._........»...,..,.....,.............,................_...................,......»................................»_(....P. �Y>
<br />......................................,.._..........
<br />SYSTEM TYPE ® 1 PRESSURE C1 2. 0 3. CONVENTIONAL SUCTION ❑... 4. SAFE SUCTION (23 CCR gz636(a)T
<br />_.»
<br />458.
<br />..._.... Q 10. RIGID PLASTIC
<br />PRIMARY CONTAINMENT ❑ I STEEL ® 4 FIBERGLASS 8. FLEXIBLE
<br />464.
<br />❑ 90. NONE ❑ 95 UNKNOWN 0 99.OTHER 464a
<br />-1.
<br />_(Specify):
<br />SECONDARY CONTAINMENT ❑ STEEL S 4. FIBERGLASS ❑ 8. FLEXIBLE6.
<br />❑ ]0. RIGID PLASTIC
<br />4646..
<br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c.
<br />PIPING/TURBINE CONTAI NMENT SUMP TYPE ❑ 1. SINGLE WALL S 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 S 4. FIBERGLASS ❑ 10. RIGID PLASTIC C190. NONE ❑ 99. OTHER (Specify):
<br />......... ........ .............. _._.... _._.......... _...................
<br />464e.
<br />_....._.........__._........... -..... .................. _......-.... .__.................. _._................ _...,_.............. ... _........_......... _....... -...... ..... -_._._.._......_...... ....... .,.... ._.... ...... _.... .......... ...,._....................... ,.................. _......_....._....._,._._......,...,_._._
<br />VENT SECONDARY CONTAINMENT ❑ L STEELS 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify):
<br />..................................._................. _._............................_._._........,,............_...........,........_..._...._.........._._.............,...._
<br />464e1.
<br />464 .
<br />......................... ....... .......... -........... _.................. _.................... _.........._... _._......... ............ _............ _.»._................ .... ..._._...._............._..._....__..,...._...---..._...._._
<br />VR PRIMARY CONTAINMENT ❑ 1. STEEL S 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify):
<br />........... _......_............_..... _._,..__........ _......___......_...........__._.._._...,._.
<br />464£1.
<br />4648.
<br />,....... .._......_._......... ..... ...... ._....._...__._...._.._._._....,.,......___.,._.._._.._.....___._..._....._.._..._._...........__.__......................._._..__......... _.........._..___._...._......_..._.._.._._..___"---'---•
<br />VR SECONDARY CONTAINMENT ❑ 1. STEELS 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify):
<br />._,.___._....___..._..,.,.....,.___...,_.....»......_._......_...__..._..._..._.._...........,
<br />464 I.
<br />464E
<br />.............................._....._...._.-._._._._._......._._..._....._„_.__.._......_......._.._,».._..»......_._....._.....__...__.____,._._................._...,........_....._._............. _.._._._._............_._._.......
<br />VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL S 2. DOUBLE WALL ❑ 90. NONE
<br />__........._._...._._......,.__......
<br />464h I .
<br />4641.
<br />... _....... _.......,......._._........ .... _._..._...................,_............__.....__.._............._,._.,.._......................_._._.,......._._............._....... __....._._......... _..............._...»......................... ..._......................... .-.... ...........,.................... _........._....._..._._,...,..._..
<br />RISER PRIMARY CONTAINMENT ❑ 1. STEEL S 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify):
<br />......,_._»._.........._....,_.._._............_.._............._._........._............_........._._.................._................._.............._..............._._......._.
<br />-
<br />4643.
<br />._........._...,._..._.._......._._._.....»_._..._._...�.......,............_....._.._..............,._............................_......._.._..__._...._...._..._...__.,...____..._._._._._
<br />RISER SECONDARY CONTA INMENT ❑ 1. STEEL S 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify):
<br />._._...,.__.._...-__._.._...__._._._...._..__..,_.__.-.
<br />464' 1.
<br />464
<br />_.__.. _.__._._. ...._. _. ..... .................... ....... ....__.._..... .._._._..__._..... ....... _............................ _.._..__....... _..................... ...................... .._....----...._..........._._................_._........_....__.._..._._...____._.-.__._...
<br />FILL COMPONENTS INSTA LLED ® 1. SPILL BUCKET S 3. STRIKER PLATEBOTTOM PROTECTOR N 4. CONTAINMENT SUMP
<br />464k 1.
<br />45la-c
<br />VII. UNDER DISPENSER CONTAINMENT (UDC)
<br />CONSTRUCTION TYPE .0 I. SINGLE WALL S 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE
<br />_.._._....._._.......»...,.--._._.._...............,.._........._........_._...._._........._......................__........_...._._.._...._._..........................__-._._._......»..._.._...._.........._.._.........,....._.__...,.,....._........__..-.__._............._............._._......_....._.._..__._...---
<br />469a.
<br />..._,,.
<br />CONSTRUCTION MATERIAL ❑ L STEEL S 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify)
<br />........,.
<br />4696.
<br />VIII. CORROSION PROTECTION.,•
<br />STEEL COMPONENT PROTE CTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION P
<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
<br />true,
<br />accurate and in full compliance with legal requirements.
<br />APPLICANT SIGNATURE: �-a°•`��- _,. ±�.'�,-1
<br />DATE 04/29/2011
<br />470,
<br />APPLIC ANT NAME (print) Chevron Products Co./ Charles Bittle 471.
<br />APPLICANT TITLE Chevron Retail HES Permit Qgsk
<br />472
<br />UPCF UST -B Rev. (12/2007) '^ey
<br />
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