|
UNIFIED PROGRAM CONSOLIDATED FORM S - Z,-71
<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 /,11, 111, IV, and IX below) 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. I DATE EXISTING UST DISCOVERED: 430b.
<br />I. FACILITY INFORMATION
<br />FACILITY ID # (Agency Use Only) 1.
<br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3.
<br />Chevron Station# 307709
<br />BUSINESS SITE ADDRESS 103.
<br />CITY 104.
<br />10858 Trinity Parkway
<br />Stockton, CA 95219
<br />II. TANK DESCRIPTION
<br />TANK ID # 32.
<br />TANK MANUFACTURER 433.
<br />TANK CONFIGURATION: THIS TANK IS 434.
<br />T
<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 437.
<br />07/01/2006
<br />8,000
<br />2 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 />❑ 6.OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a.
<br />_ ,_.._..................... _ _ _.. ...,.-._.._...__............_._._..__......._._...._._...-....__..._..._.,_._...._........__.._._.._..._._..._....._.._.._..._........................._..--.--.-..........................,..-....._......__..............._........_....._
<br />----..,.,._._
<br />CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ 1c. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440.
<br />3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS
<br />❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440a.
<br />....................... _......._....... ......,....._,..._.. .... _.... ..............
<br />NO N -PETROLEUM: ❑ 7. USED OIL ❑ IT ETHANOL
<br />-44-44. - 44. OTHER NON -PETROLEUM (Species 440b.
<br />IV. TANK CONSTRUCTION
<br />TYPE OF TANK ❑ 1. SINGLE WALL Z 2. DOUBLE WALL ❑ 95. UNKNOWN 443.
<br />_........._._,....._...._.._.....................----.........................-----._..._._.__........_._..............................._......._......_.__.........._...-................_...,....--...._._._._.._._
<br />...
<br />PRIMARY CONTAINMENT C11. STEEL Z 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444.
<br />_..._,._...._._..._._..._..,............,........................0 7. STEEL + INTERNAL UNKNOWN 0_ 99.OTHER (Specify. 444a.
<br />_LINING _._...... -..,._...,,._0,...95;
<br />SECONDARY CONTAINMENT ❑ I. STEEL ....._..._............._......................,..._...._.......__.._....__..... a4s.
<br />® 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED
<br />�_._90.NONE 95. UNKNOWN OTHER 445a.
<br />_..__..........-............ _ ......,.._._......_....El ................_❑.._99. _(Specify):-..........,......
<br />OVERFILL PREVENTION ® I. AUDIBLE & VISUAL ALARMS ® 2. BALL FLOAT ❑ 3. FILL TUBE SHUT-OFF VALVE ��- 452.
<br />❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT
<br />V. PRODUCT / WASTE PIPING CONSTRUCTION
<br />PIPING CONSTRUCTION ❑ 1. SINGLE WALL 02. DOUBLE WALL ❑ 99. OTHER (Specify) 460.
<br />SYSTEM TYPE ® 1. PRESSURE ❑ 2. GRAVITY ❑ 3: CONVENTIONAL SUCT_I.ON ❑ 4. SAFE SUCTION [23 CCR §2636(a) 3)] 458.
<br />.. ... .. ........ .................._._...----. .._........---464 ...
<br />PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE - ❑ 10. RIGID PLASTIC
<br />❑ 90. NONE UNKNOWNT-„ 99. OTHER (Specify): 464a
<br />-0•„_95.
<br />SECONDARY CONTAINMENT ❑ 1. STEEL Z 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b.
<br />❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER (Specify): 464c.
<br />__._._._._.._._..............._..._.._..._...._..._..,....,._.. .... ................ ........ ........_._._,...,_.
<br />PIPING/TURBINE CONTAI NMENT SUMP TYPE ❑ 1 .SINGLE WALL Z 2. DOUBLE WALL ❑ 90. NONE 464d.
<br />VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTIO N
<br />VENT PRIMARY CONTAINMENT ❑ I.STEEL ® 4. FIBERGLASS El 10, RIGID PLASTIC [190. NONE [1464e.
<br />99.OTHER (Specify): 464el.
<br />VENT SECONDARY CONTAINMENT ❑ L STEEL Z 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify): 46441
<br />__..... _ _.__...._ __.._._.__..,._.,....._.__,...._._.__.._.__._.._...._............,._......-.. - ....._.......................___................................._......_._..._.. -_....__._.._....................................._......._........
<br />._........ ... ...--_......._.,.....
<br />VR PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC El90. NONE ❑ 464g. 99.OTHER (Specify): 464,1,
<br />....._.___._.._...._..._ .......464
<br />VR SECONDARY CONTAINMENT ❑ 1. STEEL Z 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify): 46441.
<br />.... ...... ........ ...._............. ..... .......... ......... ...... .._._.......................... ...... .................... _.,............ ..... ......... ............................................. ......-........._.......... ................................................................._..__....._..._........,..,........................................................................._......,..,_........_........-
<br />464i.
<br />VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL Z 2, DOUBLE WALL ❑ 90. NONE
<br />_._.._..........._..._...__._.._.........._....._._....__._._._...................._......__.,_._..........
<br />-- _ ........,,....,_.__....._....,._._...._._..._..__......._....................._..............._..... _..___-.._.._....__...__.__._........__._........_.......... ,_.................. - ......... .... _._..
<br />RISER PRIMARY CONTAINMENT ❑ I. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER4641.
<br />(Specify):a641.
<br />_._.._...... - - - 464
<br />RISER SECONDARY CONTAINMENT ❑ I. STEEL Z 4. FIBERGLASS ❑ l0. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 46441.
<br />.._..............._..._...,__...,..._.�.__._._._.._...._.........._..._-....._.
<br />_......_...__....._......................................_._..._....._........__.._..__...__...._......,._.._.._.__......__........
<br />FILL COMPONENTS INSTA LLED Z 1. SPILL BUCKET ® 3. STRIKER PLATE/BOTTOM PROTECTOR ® 4. CONTAINMENT SUMP 45la-c.
<br />VII. UNDER DISPENSER CONTAINMENT (UDC)
<br />CONSTRUCTION TYPE Q -1 SINGLE WALL Z 2. DOUBLE
<br />............... .............. ............... _.._..........._...._._._._.__....__..............._....._...._..._.
<br />CONSTRUCTION MATERIAL ❑ 1. STEEL Z 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4 96.
<br />VIII. CORROSION PROTECTION
<br />STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448.
<br />IX. APPLICANT SIGNATURE`'
<br />CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the informatiorrprovided herein is true,
<br />accurate, and in full compliance with legal requirements.
<br />APPLICANT SIGNATURE:'- ���`-
<br />DATE 04/29/2011 470
<br />APPLIC ANT NAME (print) Chevron Products Co./ Charles Bittle 471.
<br />APPLICANT TITLE Chevron Retail HES it Desk 472.
<br />UPCF UST -B Rev. (12/2007)
<br />
|