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of Wi ED PROGRAM CONSOLIDATED FO / rO� UNDERGROUND STORAGE TANK / OPERATING PERMIT APPLICATION- TANK INFORMATION (One forth per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,,/!,III,IV,and IX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a. DATE EXISTING UST DISCOVERED: 43M I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ O O O _ 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 7-Eleven#32190 BUSINESS SITE ADDRESS Im. CITY 104. 4943 S. State Route 99 Stockton II. TANK DESCRIPTION TANK ID#Q�X50�3 43z. TANK MANUFACTURER 633. TANK CONFIGURATION:THIS TANK IS 434. 001 Xerxes ® 1.A STAND-ALONE TANK Complete can page foreach DATE UST SYSTEM INSTALLED 435. ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 6/2003 15,000 III. TANK USE AND CONTENTS TANK USE M la.MOTOR VEHICLE FUELING ❑ It.MARINA FUELING ❑ AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Inclutlea Used Oil) 5.❑ 5.EMERGENCY GENERATOR FUEL[HSC¢252B1.5(c)] __❑_ 6.OTHER GENERATOR FUEL _❑ 95.UNKNOWN 777_-___-__-._0 99_OTHER(Specify): 439.. CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED . ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ____,.________-.-.-.-.___-_-_❑ &PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Srcify): 440x. _---------------- _ --- NON-PETROLEUM:�] 7.USED OIL X10.ECHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OFTANK [3 1.SINGLE WALL_® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. --- _ _______ ___.__._..-.-......________________._..________ ______-__ PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4a•t. 137STEEL+INTERNAL LINING 7777[3 95.UNKNOWN Q 99.OTHER(�ify)_ 444x. SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4a5a. __ _______ __-. ___________ _._._._ OVERFB,LPREVENTTON ® I.AUDIBLE&VISUAL ALARMB ❑ 2.BALLFLOAT ® 3.FILLTUBESHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ L SINGLE WALL ® 2.DOUBLE WALL _ ❑ 99.OTHER 460. ___-_-_ _________..______.-_______________ SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY � 3.CONVENTIONAL SUCTION 458. t7 4.SAFE SUCTION[23 CCR¢2636(a)(3)] PRIMARY CONTAINMENT ❑ 1.STEEL _________......... _____ ___.._- ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC aha. ___ [390.N0N_E [195.UNKNOWN _[199.OTHER(Specify): 464.. SECONDARY CONTAINMENT ❑ 1.STEEL [14.FBERGLASS ® 8.FLEXIBLE-_------ ❑ 10.RIGID PLASTIC -----4646. _ ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. .__7276_____...-77.77___ 7777__ P�ING/I'URBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 46ad. VI. VENT,VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46 eei -____.____-.................7777__- ___ 7777__ 7777_ 777.7_-___ _ VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464E __...........__-._______________ VR PRIMARY CONTAINMENTPLASTI ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): mss' _ 7777_..............__. ____________.___..._ VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC M 90.NONE ❑ 99.OTHER(specify): 6' _2D_0__ _.-.._.-_____................ .. -_ 7777___ VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2DOUBLE WALL E-3-9-l.NONE ' ___- ________.-_________-_ RISER PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): �, ------------___............... ____-____ ___7777__ 1 RISER SECONDARY CONTAINMENT ❑ i.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464k. ___ .__ _.________...._..________.____._ __ __ __ 464kl. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL __ [13.NO DISPENSERS ❑ 90.NONE 469x. _ __ CONSTRUCTION MATERL4L ❑ 1.STEEL - HER(Specify)_-�-------� _____ ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER( ��' 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION U8. 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. rL 3r �o C APPLICANT NAME(print) Ian Moorhead 671APPLICANTTITLE Env. Compliance Mgr. 072. UPCF UST-B Rev.(12!2007)-1/2 www.unidocs.org