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&7D PROGRAM CONSOLIDATED FO - ()) /�� UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One formper uST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections I,U,III,IV and LYbelow) e�7 o. ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT C] 5.CHANGE OF INFORMATION � IC l B 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 436• 1 DATE EXISTING UST DISCOVERED: 4306, I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Safeway Fuel Station 2707-10 BUSINESS SITE ADDRESS 103. 1 CITY 104. 6425 Pacific Ave Stockton H. TANK DESCRIPTION TANK ID# /��, p 701>7i TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANKIS 434. 2A Modem Welding ❑ 1.ASTAND-ALONE TANK complete ane pagc tb,each ® 2.ONE IN A COMPARTMENTED UNIT tinct he iL DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 4/2004 10,000 2 M. TANK USE AND CONTENTS TANKUSE a U.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ It.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Induces Used Oi0 ❑ S.EMERGENCY GENERATOR FUEL[HSC§25231.5(c)I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Swify): 439. CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 446. IR 3.DIESEL ❑ 5.JET Fm ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL [IRP ETROLEUM Specify): 446. NON-PETROLEUM: 7.USED OIL 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LR41NG ❑ 95.UNKNOWN ❑ 99.OTHER ): 444. SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4as. OVERFILL PREVENTION ® 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 ® 2.DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION M CCR§2636(,X3)) 45R PRIMARY CONTAINMENT ❑ t.STEEL ❑ 4.FIBERGLASS Is S.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464% SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® s.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER( ): 464e PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WAIL ❑ 9o.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): 464e 464x7. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): n VR PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46491. 4g. VR SECONDARY CONTAINMENT ❑ L STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4601. VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464L RISER PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC [190.NONE ❑ 99.OTHER(Specify): 414, . RISER SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRJKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451x-. 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 ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 06� VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT 6.ISOLATION 448. DL APPLICANT SIGNATURE CERTEFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is trues accurate, d in full compliance with legal requirements. APPLICANT SIGNATURE DATE June 4,2009 070 APPLICANT NAME(print) Butch Hobson 471' APPLICANT TITLE Safety and Env. Affairs Mgr 972