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.wdFIED PROGRAM CONSOLIDATED FO.S1 UNDERGROUND STORAGE TANK -TANK INFORMATION (One form per UST) OPERATING PERMIT APPLICATION TYPE OF ACTION (Check one item only. Fora UST closure or removal,complete only this section and Sections f,lf,Ilf,/V,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 Viha DATE UST PERMANENTLY CLOSED: 430.. 1 DATE EXISTING UST DISCOVERED: 430n. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - 0 0 0 - 2 4 7 9 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. 7-Eleven# 17334 BUSINESS SITE ADDRESS 103. CITY IM_ 4501 PershingAve. Stockton II. TANK DESCRIPTION TANK ID# f) 5..7 S� 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434. 001 (j Total Containment ® 1.ASTAND-ALONE TANK Complete one Page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compaoment in the unit. DATE UST SYSTEM INSTALLED 435 1 TANK CAPACITY IN GALLONS 436, 1 NUMBER OF COMPARTMENTS IN THE UNIT 437. 4/1998 10,000 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ineluaes Uurl OrO ❑ 5.EMERGENCY GENERATOR FUEL IHSC§15281.3(c)1 -_-_ ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43%. __.. .............__-__.. _....._ __.._.............-.--...-_.-___.-__-._._.-.._--- CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED ❑ 16.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9 OTHER PETROLEUM(SPacL aaoa. NON-PETROLEUM: 7.USED OIL �(10 ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 44 K IV. TANK CONSTRUCTION TYPEOFTANK _❑ 1.SINGLE WALL ® 2.DOUBLE WALL___ [195.UNKNOWN a43, FRI ARY CONTAINMENT ® 1.STEEL ❑ 3 FlBERGLASS ❑ 6 INTERNAL BLADDER _ aaa. _ _❑ 7.STEEL+INTERNAL LINING __ ❑.95 UNKNOWN -[_99..OTHER(Specify): 444x. SECONDARY CONTAINMENT [31.STEEL ❑3 FIBERGLASS ❑ 6 EXTERIOR MEMBRANE LINER ® 7.JACKETED 445. ❑ 90.NONE ❑ 95 UNKNOWN [199.OTHER(Specify): 445x. OVERFILL PREVENTION - -- -- -�-- ® 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 432. ❑ 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 aw. SYSTEM TYPE ® 1 PRESSURE .❑ 2 GRAVITY -0 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTIONI 3CCR§2636( N3)I 458. PRIMARY CONTAINMENT --- -- �- ❑ 1.STEEL ❑ 4.FlBERGLASS ® B FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE _ [3W ❑ 99.OTHE 95_UNKNON _____ R(Specify):_ 46,la. SECONDARY CONTAINMENT t] 1.STEEL ❑ 4.FIBERGLASS 19 8.FLEXIBLE ❑ 10.RIGID PLASTIC a6ab. ❑ 90.NONE __ ..........95 UNKNOWN WN r_199 OTHER(Specify): PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1 SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRUAARY CONTAINMENT ❑ 1 STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4�. 11 VENTSECONDARY CONTAINMENT [I1 STEEL ❑ 4 FlBERGLASS ❑ 10 RIGID PLASTIC ® 90.NONE [199.OTHER(Specify): VR PRIMARY CONTAINMENT ❑ I STEEL ® 4.FlBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): aro g. ...... ...._ ........ ._ s-. VR SECONDARY CONTAINMENT ❑ I STEEL. ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): a4 6 . -_-. -.-- _......-.... _._ -_______ .___. _._. -.._ _ ...___ VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE .-. _._ _ -.__ -------------------- ._____- .. ___.-_- -.......-.-_ aha) RISER PRUAARY CONTAINMENT ❑ I STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify). 46x1 ..... __ ..... F...'-----'--_ ...._ . .......-_ . .....- _ RISER SECONDARY CONTAINMENT ❑ 7 STEEL ❑ 4.FIBERGLASS- ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464k. FILL COMPONENTS INSTALLED ® 1 SPILL BUCKET ® 3 STRIKER PLATEBOTTOM PROTECTOR 4551., ❑ 4.CONTAINMENT SUMP VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1 SINGLE WALL ❑ 2 DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469, CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS [110.RIGID PLASTIC [1 99 OTHER(Specify) --.. Q9,. VIII. CORROSION PROTECTION -C1 STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODES) E] 4.IMPRESSED CURRENT fi.ISOLATION 44F_ IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the harardous substance stored and that the information provided'lteretn is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) Ian Moorhead n71. APPLICANT TITLE Env. Compliance Mgr. 472 UPCF UST-B Rev.(1212017)-1/2 www.unidocs.org