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U IFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK I Q1 lv OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per USt 2 TYPE OF ACTION (Check one item only. Foran UST permanent closure or removal,complete only this section and Sections 1,II,III,N,and IX below) 470 El 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.LIST REMOVAL DATE UST PERMANENTLY CLOSED: e3o. DATE EXISTING UST DISCOVERED 43M 1. FACILITY INFORMATION FACILITY 1D K(Agency Use Only) _ _ -L 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business AS) V Circle K#2701205 BUSINESS SITE ADDRESS lac CITY 704 16470 Cambridge Lathrop Il.TANK DESCRIPTION TANK IDK 1 432 TANK MANUFACTURER 433 TA.NKCONFIGURATION: THIS TANK IS 474 Owens Coming ®1.A STAND-ALONE TANK � '� ? ❑2.ONE IN A COMPARTMENTED UNIT DATE UST SYSTEM INSTALLED 425 [NUMBER COMPARTMENTS inm4IN' TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT +77 11849 1 III.TANK USE AND CONTENTS TANK USE ® Is MOTOR VEHICLE FUELING ❑ lb.MARINAFUELING ❑ to.AVIATION FUELING439 [13.CHEMICAL PRODUCT STORAGE C] 4.HAZARDOUS WASTE(ixiuin Gae,1 oil) ED5,EMERGENCY GENERATOR FUEL(HSC g2528L5(.)I ❑ 6.OTHER GENERATOR FUEL O 95.UNKNOWN ❑ 99.OTHER(Specify): 439. CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ to.MMGRADE UNLEADED ❑ Ib.PREMUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Speci44oa NON-FETROLEM:❑ 2 USED OIL ❑ 10.ETHANOL ❑ I1.OTHER NON-PETROLEUMS ifv): 44m IV. TANK CONSTRUCTION TYPEOFTANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 447 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify). 9440 SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99,OTHER($ if : 4450 OVERFILL PREVENTION ❑ I.AUDIBLE&VISUAL ALARMS ❑ 2.13AI,L 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 ❑L SINGLE-WALLED ®2.DOABLE-WALLED ❑99.OTHER 460 SYSTEM TYPE R1 PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ C SAF-SUCTION[:r;CCR§2636(.X7)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS 0 8.FLEXIBLE ❑ 10.UGID PLASTIC 4M ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,OTFIER Specif7•), 0640 SECONDARY CONTAINMENT ❑ 1.STEEL 22 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC +bob ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,OTHER(Specify): 4609 I PIPINGITURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464,1 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL ® 4.FIBERGLASS ❑ 10.RI OLD PLASTIC 90.NONE 99.0THER(Specify) 461e 4C e3 VENT SECONDARY CONTAINMENT E3 1.STEEL D 4.FIBERGLASS 0 10.RIGID PLASTIC 90,NONE 0 99.OTHER(Specify) 4Mf 6fl VR PRIMARY CONTAINMENT ® i.STEEL ❑ 4.FIBIIeCLA55 ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 4646 VR SECONDARY CONTAINMENT El1.STEEL E34.FIBERG[,aSS 0 IO.RIGR)PLASTIC 90.NONE [3464 5 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE Owl RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS LJ 10.RIGIDPLASTIC ❑ 90.NONE El 99,OTHER(Specify) 464) 4641 RISER SECONDARY CONTAINMENT E3 L STEEL ❑ 4.FIBERGLASS 10,RIGID PLASTC-0 90.NONE 0 99.OTHER(Specify) 46 461kl FILL COMPONENTS INSTALLED L SPILL BUCKET In 3.STRIKER PLATE/BOTTOM PROTECTOR 4 CONTAINMENT SUMP 451. VII, UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL M 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER fS ify) M469 VIII, CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 4+a. IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in f ii compliance with legal re uiremenm APPLI ANT ATl}nj_ /j *SATE �j I�l(I azo. APP ANT AME(print) -�� C�� / 41_ APPLICANTTITLE Environmental Compl. Mgr. 4n. UPCF UST-B-112 Rev.(12t2007)