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IFIED PROGRAM CONSOLIDATED Feq UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections L II,III,IV,and IX below) 430 X 1.NEW PERMIT ❑ 3.RENEWAL PERMIT El 6.TEMPORARY UST CLOSURE [17.UST PERMANENT CLOSURE ON SITE ❑ 5.CHANGE OF INFORMATION ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: a3oaDATE EXISTING UST DISCOVERED: 4301, I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 7-Eleven#32190 BUSINESS SITE ADDRESS 103 CITY 104 4943 S.State Hn 99 Stockton H.TANK DESCRIPTION TANK ID Il 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Xerxes X 1.A STAND-ALONE TANK 3 ❑ 2.ONE IN A COMPARTMENTED UNIT. Com lete ace,pup for each compartment is the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Unknown 10,000 1 III.TANK USE AND CONTENTS TANK USE x ]a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ ]c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil ❑ S.EMERGENCY GENERATOR FUEL[HSC§25281.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED x lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 44oa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL x 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL X 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 44sa SECONDARY CONTAINMENT ❑ 1.STEEL X 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4a5a OVERFILL,PREVENTTON ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT x 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION x 1.SINGL&WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE x L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.)(3)] 458 PRIMARY CONTAINMENT ❑ L STEEL X 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ l0.RIGIDPLASTTC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTTC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464. 464.1 VENT SECONDARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E 464f1 VR PRIMARY CONTAINMENT ❑ 1.STEEL z 4.FIBERGLASS ❑ 10.RIGID PLASTTC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mg 464 I VR SECONDARY CONCAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTTC x 90.NONE ❑ 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL x 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4 j 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC x 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED x 1.SPILL BUCKET x 3.STRIKER PLATE/BOTTOM PROTECTOR ❑4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE x 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.UAPRESSED CURRENT ❑ 6.ISOLATION 448. 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, andip1gcompliance with 1 al requirements. APPLICANT SIGNATURE �� DATE 1� � o9 a7o. APPLICANT NAME(print) Dulcinea Webb ... APPLICANT TITLE Compliance Manager <72. UPCF UST-B-1/1 Rev.(12/2007)