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IED PROGRAM CONSOLIDATED Flo 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 1,IL III,IV,and IX below) 430 X 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 43% I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILTTY NAME or DBA-Doing Business As) 3 7-Eleven#32190 BUSINESS SITE ADDRESS 103 CITY IN 4943 S.State Hwy 99 Stockton II.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Xerxes X 1.A STAND-ALONE TANK 1 ❑ 2.ONE INA COMPARTMENTED UNIT. Com lets one pm,for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Unknown 15,000 1 1 III.TANK USE AND CONTENTS TANK USE x Ia.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Mcludee Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439. CONTENTS PETROLEUM: X la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ 16.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): Ono. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM S eci : 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): 444e SECONDARY CONTAINMENT ❑ 1.STEEL X 3.FIBERGLASS ❑ 6.EXTERIOR NIEIvIBRAF1E LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 445. OVERFILL PREVENTION ❑ 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.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE x L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.)(3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL X 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL x 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPINGtrMINE 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 ❑ 1.STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL x 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641' 464B VR PRIMARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CObNTAWMI Nf ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC x 90.NONE ❑ 99.OTHER(Specify) 46411 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL x 2.DOUBLE WALL ❑ 90.NONE RISER PRIMARY CONTAINMENT ❑ 1.STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 4641 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC x 90.NONE ❑ 99.OTHER(Specify) 464k 46441 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) 469ba VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED 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, an -kano-k fall compliance with legal requirements. 470. APPLICANT SIGNATURE �- „ ,_� Q� DATE �✓ .tea -1 - k- U5 APPLICANT NAME(print) Dulcinea Webb 471. APPLICANT TITLE Compliance Manager 472. UPCF UST-B-1/1 Rev.(12/2007)