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1fW1ED PROGRAM CONSOLIDATED FQ% / UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION- TANK INFORMATION (one f(((orm Per LIM TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,,11,I f,/V,and JX below) �y 1/ 30. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION -1 t/ ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430., 1 DATE EXISTING UST DISCOVERED: 4306. I. FACILITY INFORMATION FACILITY ID#(Agency Use only) -10 0 0 1-12 ITT 9 1. BUSINESS NAME(Same as Facility Now or DBA-Doing Business As) 3 7-Eleven# 17334 BUSINESS SITE ADDRESS 103. 1 CITY Pu. 4501 Pershing Ave. Stockton II. TANK DESCRIPTION TANK ID# --r�il C� S" 7 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434_ 002 `f- Total Containment ® 1.A STAND-ALONE TANK Complete am page for eah DATE UST SYSTEM INSTALLED 435. ❑ 2.ONE INA COMPARTMENTED UNIT compmaem in rhe unit. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 4/1998 10,000 III. TANK USE AND CONTENTS TANK USE N la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ IAVIATIONFUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(1nJudes Used O0.1) ❑ S.EMERGENCY GENERATOR FUEL IHSC§25281.5(cp __PE❑ 6.OTHER GENERATOR FUEL [3 95.UNKNOWN _ _ [I99._OTHER(S�ecify): 43%. CONTENTS TROLEUM: ❑ la.REGULAR UNLEADED [3IC.MIDGRADE UNLEADED ® 113.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): a40a. ..._-___.__--__. __.-_..................__ -.__-__ ............__.-..... ........._._ NON-PETROLEUM-TT USED OIL � 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S cif): aMlb. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRBv1ARY CONTAINMENT --- ..___.__ '_ ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6 INTERNAL BLADDER ----- ---- ----------444. _ ❑ 7.STEEL LINING _❑_ 95.UNKNOWN _ __ ___--CO _ .. _ 99.OTHER(specify): aa4a. SECONDARY CONTAINMENT ❑ 1 STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ® 7.JACKETED _ _ _ _ ❑ 90.NONE ____❑ 95 UNKNOWN ❑99.OTHER(Specify): 445a. OVERFILL PREVENTION ® 1 AUDIBLE&VISUAL ALARMS ❑ 2 BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 45x. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ® I PRESSURE Q 2 GRAVITY ❑ 3 CONVENTIONAL SUCTION ❑ - SAFE SUCTION Ix3 CCR12636(aX3)I 458. PRIMARY CONTAINMENT _..... ___ ...... ❑ 1.STEEL ❑ 4.FIBERGLASS ® B.FLEXIBLE ❑ 10 RIGID PLASTIC 464. _ _ [_ 90_NONE 0_95_UNKNOWN.................❑-99_OTHER(Specify): 46a. SECONDARY IN [IL STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. _ -____. .,,.,,., . ❑ 90.NONE ----- 1- 95.UNKNOWN ___❑ 99.OTHER(Specify): abac. P�INGII'URBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644: VI. VENT, VAPOR RECOVERY(VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.S I1 1 1. ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify)' 464a __ _____.._.. --_-. ....................____ 969e1. VENT SECONDARY CONTAINMENT ❑ L STLI 1 [IFI 4 BERGLASS [110.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): ... .............. -------- ______. _ VR PRIMARY CONTAINMENT [J1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify) g6yg. VR SECONDARY CONTAINMENT ❑ 1 STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464. VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464` .............._..... ....______ . .-----------___ __ ..............._ RISER PRIMARY CONTAINMENT t] 1 STEEL ® 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4MI' RISER SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): -. .......-. ...-..-.. _ ......... FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4SIa<. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1 SINGLE WAIT ❑ 2 DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. CONSTRUCTION MATERIAL ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696' 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION aaa. IX. APPLICANT SIGNATURE r CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided hepein is true, accurate and in full compliance with legal requirements. C. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) Ian Moorhead 471, APPLICANT TITLE Env. Compliance Mgr. 471 UPCF UST-B Rev.(1212007).1/2 www.unidocs.org