|
UNFFIED PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One fbm per us )
<br /> TYPE OF ACM014 (Check'ales'1,VX WtK For a UST clomw or mmml.comkic,mtv this swilon and Sections 1,11,1/1,7V,and IX below) 430.
<br /> [:3 1.NEW PERMIT 3.RENEWAL PERMIT [1 5.CHANGE OF INFORMATION
<br /> [,,7'BMPORARY UST CLOSURE 7.USI'PERMANENT CLOSURE ON SITE Q is,UST REMOVAL
<br /> DATE LIST PERMANENTLY U I'D: 439- 1 DATE EXISTING UST DISCOVERED; 430b.
<br /> 1. FACILITY INFORMATION 7-7
<br /> FACILITY 10#(Agency Use 0*) 1- 1 1 -1 1 F -
<br /> BUSINESS NAME(Sam as Faculty Nmw or DBA Doing BwiwsxAx)
<br /> Chevron Station#96171 CITY ror
<br /> BUSINESS SITE ADDRESS 103.
<br /> 6633 Pacific Ave I 'SiOelcton,CA 95207
<br /> U. TANK DESCRIPTION
<br /> TANK ID 0 432 TANK MANUFACTURER 422. TANK CONFIGURATION:THIS TANK IS 434.
<br /> 0 1.ONE
<br /> c=V11"am Pw rut am
<br /> 3 XLIRXES 0 2,ONE INA COM;;ki UNIT --W-iR the urdL
<br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437.
<br /> 01/01/1986 10,000 0
<br /> M. TANK USE AND CONTENTS
<br /> TANK USE I@ in.M(TrOR VEHICLE FUELING r] 1b.MARINA FUELING 0 Ic.AVIATION I-VELING 439.
<br /> [3 3.CHEMICAL PRODUCT STORAGE C3 4,HAZARDOUS WASTE(InkWo VoW Oii) [] 5.EMERGENCY UFNF-RATOR FUEL IHsc#25261.5(c)j
<br /> [3 6,OTHISSR GENERATOR FUEL 095,UNKNOWN [3 99,CMIER(Speci!yj! 43%.
<br /> CONTEN'r-S PETROLEUM; [3 In.REGULAR UNLEADED [3 Ic.MIDGMADE UNWZr-.6 0 jt,.PREmrumuNLEADr-*t) 440.
<br /> C) 3.DIESEL, [3 S.JET FUEL E3 6.AVIATION GAS
<br /> ❑ 9.PETROLEUM BLENDFUEL 0 1 9.OTIWIR PETROLEUM
<br /> 7.USED OIL 10.ETHANOL
<br /> NON FOWULMOWF01-
<br /> 11.OTHER NON-FFM01-F11M(SPwjfif),-- 440b.
<br /> IV. TANK CONSTRUCTION
<br /> TYPE OFTANK 13 I-SINGLE WALT. 0 2.DOUBLE WALL UNKNOWN 443.
<br /> PRIMARY CONTAINMENT E3 I,STCFL N 3.FIBERGLASS E3 6.INTERNAL BLADDER 444a. 444.
<br /> [37.317.F%+IN-1-14ANAL LININGQ 95.UNKNOWN 13 99,OTHER(Sv-ify):
<br /> SEC DARY CONTAINMENT C) 1,STEEL IN 1.FiBlatGLASS 0 d.EXTERIOR W-M9RANELINER 13 7,JACfcnFD 445,
<br /> 13FNONF 0 95.UNKNOWN 445L
<br /> RRFILL PREVENTION 9 LAUDIBI-RAVINtIALALARMS [12.BALLELOAT 0 3.FILL TUBE S1 VALVE 452.
<br /> E3 4,,rANK MEETS REQUIREMENT$FOR EXEMPTION FROM OVLRI;11,L PREVENTION EQUIPMENT
<br /> V. PRODUCT/WASTE PIPING CONSTRUCTION
<br /> PIPING CONSTRUCTION E3 1.SINGLE WALL 0 2.DOUELE,WALL 0 a.OTIM R 4a
<br /> SYSTEM TYPE 0 1.PRESSUR ' L"r4vM11LMn0N C34 SAFE SUCTION E)-ccr-i2ow-na............!n-
<br /> ,P 2.GRAVITY WJ'.. AL SUCTION
<br /> PRIMARY CONTAINMENT 0 1.STEEL 0 4 FIRFROLASS ❑ 6,FLEXIBLE 0 10,RIGH)PLASTIC 464.
<br /> M 90.NONE Q 95,UNKNOWN ❑ 99,CM-M-K(Specify 464e. 464b.
<br /> SECONDARY CONTAINMENT C31.STEM 10 4.FIBERGLA8% 0 S.FLEXIBLE.; [110.RIGID PLASTIC 46ft
<br /> [3 90.NONE [1 95.UNKNOWN [3 99.OTHER(SP*Wfy); .
<br /> PIPING JTURBINE CONTAINMENT SUMP TYPE 0 L SINGLI,,WALL Q 2:4�UMM WALL 13 W.NONE464d
<br /> _
<br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION
<br /> VENT PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC [390,NONE 0 99,OTHER(Spoeify)!
<br /> 464f,
<br /> VENT SECONDARY CONTAINMENT 0 1,STEEL C3 4.PIHERGLASS L] 10,M010 MASTIC 0 90.NONE E3 99,OrIUM(Specify): 464n.
<br /> RIGID 13 NON OTHER -yT
<br /> VR PRIMARY CONTAINMENT (3 1,STEEL iiiiGI-A-5% [3 10. PLASTIC ❑ 90. E 13 99. (Specify);
<br /> 464
<br /> VR SECONDARY CONTAINMENT [1 1.STEEL E3 4.FIRFROLASS [] 10.RLQD PLASTIC 10 90.NONE [1 99.OTHER(SIWWjry): ---4661.
<br /> VENT PIPING TRANSITION SUMP TYPE C3 1.juNGLE WALL L3 2.DOUBLE WALL 1@ 90.NONE 464F
<br /> RISER PRIMARY CONTAINMENT 1.STELL [1 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify):
<br /> RISER SECONDARY CONTAINMENT C) I-STEML E3 4.FIBERGLASS E3 10,RKHD R.AXric 0 v).NONE E3 99.OTIHIR(Spw.*)'. 464k1.
<br /> FILL COMPONENTS INSTALLbO 0 1.SPILL BUCKET 0 3-STRIKER.PLATI1911OTTOM MOTEC-TOR IM 4.CONTAINMFNTSUMP 451--
<br /> ER DISPENSER CONTAINMENT (UDC)
<br /> CONSTRUCTION TYPE 23 1,SINGLE WALE. 0 2.DOUBLE WALL LI 3.NO DISPE.NSERS 1-1-0 90.NONE 40&
<br /> CONSTRUCTION MATERIAL 13 1,STEEL 9 4.FIBERGLASS (3 10.RIGID PLASTIC C] 99,atHER(Specify) 40C.
<br /> VIII. COMOSION PROTECTION
<br /> STEEL COMPONENT PR(YMCI'ION [3 2.SACRIFICIAL ANOIJWS) E3 4.IMMESS M- CURRENT 0 6.ISOLATION 448
<br /> IX APPLICANT SIGNATURE
<br /> CERTIFICATION: I ceNfy that this UST system is compatible with the hazardous stibstance stored and that the information provided herein Is true,
<br /> =orate.and in full compliance with Igg Mguirements. 470.
<br /> APPLICANT SIGNATURE:T'9tAq)MAgUN&Z' DATE 01/12/2009
<br /> APPLICANT NAME((1rint) Chevron PrWuebCoJf-'[tL-DMAKriNr.z 47" APPLICANT TITLE Retail HES Pen-nit Desk 472.
<br /> UPCF UST-B Rev.(12=7)
<br /> TTOP VRIDV 0aUVH3fI zC90 US SZ6 xVA 0r:60 6002/zz/zo
<br />
|