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D PROGRAM CONSOLIDATED FORW CP / UNDERGROUND STORAGE TANK I d5 OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,I,III,IV,and LYbelow) (x B [I1.NEW PERMIT ® 3.RENEWAL PERMIT C35.CHANGE OF INFORMATION a It 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430: 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ 2 O 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Safeway Fuel Station 2707-10 BUSINESS SITE ADDRESS 103, CITY 104. 6425 Pacific Ave Stockton II. TANK DESCRIPTION TANKID# TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 1 Modern Welding ® 1.A STAND-ALONE TANK c0a late ova Page fv e ❑ 2.ONE IN A COMPARTMENTED UNIT ecaPam is the wit DATE UST SYSTEM INSTALLED 436. TANK CAPACITY IN GALLONS 416. NUMBER OF COMPARTMENTS IN THE UNIT 437. 4/2004 20,000 1 M. TANK USE AND CONTENTS TANK USE N Ia.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ l9.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(hwluGs UndOil) ❑ S.EMERGENCY GENERATOR FUEL[RSC§25281.5(0)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify); 439a, CONTENTS PETROLEUM: N la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Sb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL - ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.0THERPETROLEUM(Specify): 440. NON-PETROLEUM:❑ 7.USED OIL ❑ 30.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4400. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT N 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444' ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444% SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.IACKETED 405 Cl 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): d45a OVERFILL PREVENTION N 1.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 99.OTHER 060. SYSTEM TYPE N 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 12636(a)(3)] 458. PRIMARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS N 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER( ecW): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RJGIDPLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Speoft 464. PIPINGITURBINE 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.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q4046, VENT SECONDARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q fl VR PRIMARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q� VR SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4 h. 464hl. VENT PIPING TRANSITION SUMP TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464` RISER PRIMARY CONTAINMENT N 1.STBEL ❑ 4.FIBERGLASS [1 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q�•�; RISER SECONDARY CONTAINMENT C] 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 464k1 FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET N 3.STRIKER PLATE(BOTTOM PROTECTOR N 4.CONTAINMENT SUMP 451:0. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469% CONSTRUCTION MATERIAL ❑ L STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 0991 c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANOD ❑ 4.IMPRESSED CURRENT .ISOLATION ae. DL 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, nd in Cull compliance with legal requirements. APPLICANT SIGNATURE DATE June 4, 2009 410 APPLICANTNAME(print) Butch Hobson 471 APPLICANT TITLE Safety and Env. Affairs Mgr 012 TMf7P r19T_1R Rn., n v7mmn-1 is www.nn:dnre.nro