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Ak An IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK 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,II,III,IV,and IX below) 430. ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a. I 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, Chevron Station#99840 BUSINESS SITE ADDRESS 103. CITY 104. 4344 Waterloo Rd. Stockton, CA 95215 II. TANK DESCRIPTION TANK ID# (t 432. TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434. 2 r XER�ES ® 1.A STAND-ALONE TANK Complete one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 03/12/1998 15,000 0 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. -._.. -._._..._._. ... ....................................................... .........._......_.................._................................_............_...................................._..._............._........._._._.._._..... _._............... CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ® 1b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND.FUEL (] 9:OTHER PETROLEUMSS�ecifx)_ 440a. .............. .............................__..............._.... ..............................._- ....... .....-............. . ....._._. _...._.._......__....-_.. NON-PETROLEUM:❑ 7.USED-0-1 L ❑ 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 LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. _....._..............._........... ..................................-....................................................__.._.............._..._......-..................................._.................. ........................ SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. _.....-- ._..........................._........_................_.. ._. .............................................:........._....._...........--...............__.._........-._-............ -_....................... 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 E UIPT%ENT V. PRODUCT-/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL [:199.OTHER 460. .............._...._......:......._...._..---.._........................_.._............................................_............................................................................._................................_................................_._.................................._.-.......................-.....................__._..._._..............._......................................................................_._......__...... SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY [1-3 CONVENTIONAL SUCTION [14.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. _........_........................._..................................................._._.._..................LA..................................-_..............�...-.....-........_..... ...............__.........__.............._ SECONDARY CONTIN AMENT ❑ L STEEL ® 4.FIBERGSS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. -........_.....- .........__......_........._.._........_........................................ ....... .................................................... ................... ....... ..................._..............__............-- .........._.........._._-.. -_..._.._.......__._..._._.. PIPING/TURBINE CONTAINMENT SUMP TYPE ® l.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® 1.STEEL [14.FIBERGLASS [I10.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 464el. ...................._..........__...._................_.._._...............__...................---.........._........_.................._...................................................................................._........................................................_....................._..................................-...................................._.........._................................................................ .....464 f.... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464£1. ..........__...................................................................................................................................._............----............_................._._....._......_.........---.---............................._................................................................................ _464......... VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify): a64g..,__ ..................................................................................................._..........................................................__.............._......_........_.........._.-.._..............._............................................ 464h. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hl. ................................................-.................................................---......................................._..............................................................................................................................._..................._.................................._........__._................................................................................................................................... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464' ........................................._.._.........-......................................----.............................._....._................................................................................................................................................._......................................_.._............................._..._.....-................_......................_........................................................................._....._...........................4 :...... RISER PRIMARY CONTAINMENT ® 1.STEEL [14.FIBERGLASS [_-] 10.RIGID PLASTIC [190.NONE [199.OTHER(Specify): g464j. .........................._...............................__........_......-.................................._........._................................................................................................................................................_.................._..............._.._......_._..................._.__..............._.................................................................................................... RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [] 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify): 46641. .................................................._-.........._......._...._.._......._....................._.............................................._._....................................................................................................__.....-_.........-..._._....._....._...._.. ..........................._.................................................................................. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 4514-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2 DOUBLE WALL ❑ 3_NO DISPENSERS ❑ 90.NONE 469a. .........................._............................._._......._...._.._.__...................._._........-.......................... ...................................... .............._...................... ........................_ . ........... _......4 --...... CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify tha this ST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and i om liance with a al requirements. APPLICANT SIGNATURE: DATE 06/10/2009 470 APPLICANT NAME(print) Chevron r cts Co./JIM HARTMAN 471 APPLICANT TITLE Retail HES Pe it PeSk "` 4 72 UPCF UST-B Rev.(12/2007)