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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGROUND STORAGE TANK ��x7 OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per usT) ;;T�YP OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,III,IV,and IX below) 430 1•NEW FErMfi Fort a? ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: "a I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ I 111F1 1 - 1111 111 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 UIK STOP MARKET#76 BUSINESS SITE ADDRESS 103 CITY 104 1030 SOUTH OLIVE AVENUE STOCKTON H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TAn CONFIGURATION: THIS TANK IS 434 #1 (RUL,8 OCTANE) XERXES FTASTAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. Compktc one past for each cornpauTea in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 NOVEMBER 51998 12 000 1 III.TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ ]b.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ 1c.MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM Sec 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 0 L STEEL W3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify); 444a SECONDARY CONTAINMENT 0 L STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS [12.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 ❑ .SINGLE WALLED .DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE Irl.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(3) 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE JErl.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVE Y(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT LJ 1.STEEL W 4.FIBERGLASS Lj 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 91905.NONE 99.OTHER(Specify) 464E 4601 VR PRIMARY CONTAINMENT 1.STEEL 214.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 4648 464&1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC FIF NONE n 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE J.SINGLE WALL C1 2.DOUBLE WALL 90.NONE 4641. RISER PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS U 10.RIGID PLASTIC U 90.NONE 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC Mr90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED Irl.SPILL BUCKET FT STRMER PLATEBOTTOM PROTECTOR W4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ffI.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 46Wc 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 providedherein Is true,accurate, and in full compliance Vth legal requirements. ~� APPLICANT SIGNATURE_f77. August 26, 2009 470. APPLICANT NAMEgnint) Mike Karvelot, 471" APPLICANTTITLE Director, Environme ffairs 472. for Quik Stop Markets,Inc. lIPCF LIST-B-1/2 RPv_(12!20(171