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• tMWED PROGRAM CONSOLIDATED FORMW 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: 430x. 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 #209167 BUSINESS SITE ADDRESS 103. CITY 104. 1234 Yosemite Ave Manteca, CA 95336 II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 2 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 437. 07/25/2000 15,000 0 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.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. -- ...__........._...................................... ..............................................................._...._......_..._...........................__.....__.................................---._.........._...._.........................._.......................................................... ....................- CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ ]c.MIDGRADE UNLEADED ® lb.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _..._..........................................................................................................._...._0..._8.._PETROLEUM BLEND FUEL 0.._9:..OTHER PETROLEUM.-(Speci�'):...... 44oa. .............................................. NON-PETROLEUM:❑ 7.USE50'IL ❑ 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 _..._.........................................................................._............._-......._....._..._._..._..............................................................................._............................- -....._ 44-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 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. _._..__......_......_......................................................................................... . O_...-._..........................................._............_......................._........................................................................_.._-._._...._---....-.. 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 4646. ___ ❑ 90.NONE ❑ 95.UNKNOWN [:199.OTHER(Specify): 464c PIPING T_ NiIN CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE ..............__...._.............tea..... 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): q64� ............._._.._...................................._......_......_.._..._._................_...-._._......................................................................................................................-------._..._............-_.._....................................................................................................._....................---- VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q46>i ................................................................................................................................................................._......................_......_......................._......_...._....._...__....._..----.................-.....__............................._...............................................................................................-................._.. .6.......... VR SECONDARY CONTAINMENT [11.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hl. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. ...............................................--.:._....._......_........................................................_.-_......................_._.._..............................................................................._................................................... ......._.................._..---._._._..-......._................................._................................................................................................... ....._... 464j. RISER PRIMNM ARY CONTAIENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ pecify): 46 99.OTHER(S41 _...._...- -..__ ._...__....................__..........................................................................................._-.............._.......---......................._..__..__........................................_................................._...-_.................................................................................................................. RISER SECONDARY CONTAINMENT [11.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): ggkj ._.._........._......-............................._......................................._.......................................................................................--.-.-.--......_...... _...._.................__..........................................................................................................._.........................._........__........................_................................... FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451 a-c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL [13.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:TT*,E(D9NARg79VEZ 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)