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. INWED 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,111,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: 430.. 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Chevron Station#209167 BUSINESS SITE ADDRESS 103. 1 CITY 104. 1234 Yosemite Ave Manteca, CA 95336 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 1 XERXES ® 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 43z 07/25/2000 20,000 0 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.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. _... ----................................._................................................................................................._..._-...._._....---.._.. --.................__.........._.............................................................. EN CONTTS PETROLEUM: ® I. REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a......................... ................................._..._............................._........... ...._...._.......---............_.............._.._..._............... ..._...._. -_....._... .......... ..... 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 LINING ❑ 95.UNKNOWN [199.OTHER(Specify): 444a. .. ..........................................._..._._................................................................................__......_................................_.__.._.........._.........._...........--.....__._......_ SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED aas. ❑ 90.NONE ❑ 95.UNKNOWN [199.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 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[23 CCR§2636(a)(3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. _ ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 464a. _._..................................-......_................ ......._................ ............................. SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS [38.FLEXIBLE ❑ 10.RIGID PLASTIC 6646. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4640. ......._...................................._.................___...._.............._.........._...__............................ _....._............._....... PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE .4.W 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): 46441. ............-._..-.-......._................ __ ..--.-._._..........................._...._............................_...._.._.................._..............._.........................---- -................_-..._....................._........_................................................__...._................._.............................. ....................... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464fl. ..........................................._..................._............----......... ---...._......................._....._.................................................................................................................................................... ...................... __.. _.._........_.._._.._..........................................1. . . a6ag. VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4664g. ---.........._._..................._.__..._...........__._................. .........................._..._............._..._-.__............. __......................................._..................................................................................................�_......._..----.._._...... VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE F-1 99.99.OTHER(Specify): 46441. ......................................._.............................._...----..__..........---..........-................._.._.................._... ....... _........................._..__........................................_._..._................................................._................................---..........-..._........................ ...............;...... VENT PIPING TRANSITION SUMP TYPE [11.SINGLE WALL [12.DOUBLE WALL ® 90.NONE 464'. ..................................._._....- -- --------.............._._........._..._..............................---......._................_-..........................------................._..................._......_........._....._....._._......-._.................__................................._...............................................................................................4�. ;. .... RISER PRIMARY CONTAINMENT ® 1.STEEL [14.FIBERGLASS [110.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 644. .................. .........--...--......_......_.................__............_......................................................................._.._.-..._..........._...- .._...._..........---...._.__..__....._._....._.......................................--......................._................................_.._.._........................... 2mi . RISER SECONDARY CONTAINMENT [11.STEEL ❑ 4.FIBERGLASS [110.RIGID PLASTIC ® 90.NONE [14644 99.OTHER(Specify): 46641 ...................................................................- ..._ FILL COMPONENTS INSTALLED ® I.SPELL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® L SINGLE WALL ® 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a. ..................................._.._.....-....._._................................................................................................................................................................................................................................................._................................................................................................................................................................_............................................-............................................... ..... 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 that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE:TggEq)A"PNNEZ DATE 01/14/2009 470, APPLICANT NAME(print) Chevron Products Co./FRED MARTINEZ 471. APPLICANT TITLE Retail HES Permit Desk 472 UPCF UST-B Rev.(12/2007)