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of AZ- Y s-,1-r UN ED PROGRAM CONSOLIDATED FOR UNDERGROUNDSTORAGETANK 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 1, 11,111,1V,and/A"Below) 410 ❑ I.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: 430e DATE EXISTING UST DISCOVERED: anon I. FACILITY INFORMATION FACILITY ID k(Agency Use Only) - - BUSINESS NAME(Sane as Facility Name or DBA-Doing Biamess As) 3 George's Mini Mart BUSINESS SITE ADDRESS 102 CITY 101 18662 N HWY 88 LOCKEFORD 11. TANK DESCRIPTION TANK ID q 2 TANK MANUFACTURER °}3 TANK CONFIGURATION:THIS TANK IS 434 T1tUSC0 ® I.A STAND-ALONE TANK ComPlae one vase for each ❑ 2.ONE INA COMPARTMENTED UNIT compannnenl in the unit DATE UST SYSTEM INSTALLED 415 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 05-28-1995 10,000 III, TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING- ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 7.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ S.EMERGENCY GENERATOR FUEL[HSC 425281.5(c)[ _❑ 6 OTHER GENERATOR FUEL C3 95.UNKNOWN , 099 OTHER(Specify): 439. ENT_ CONTS PETROLEUM: ® la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL CI OTHER,PETROLEUM(Specify)_ 140n NON-PE'fROLEUM ❑ 7.USED OIL ❑ 10 ETHANOL ❑ 1 L OTHER NON-PETROLEUM(Specify): 440b' IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2 DOUBLE WALL ❑ 95 UNKNOWN _ d43 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3 FBERGLASS ❑ 6.INTERNAL BLADDER ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN_ ❑ 99 OTHER(Specify), 4144 SECONDARY CONTAINMENT ❑ 1 S'fF-FL ®} FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7 JACKETED 4Jj ❑ 90 NONE ❑ 95 UNKNOWN [199.OTHER(Specify$ OVEILL PREVENTION ® I.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 45' RF ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT V. PRODUCT /WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I.SINGLE WALL ❑ 2 DOUBLE WALL ❑ 99,OTHER 460. .... "_..._ ___ ....__ ___. ...."__ O ..."__ __... 4518 SYSTEM TYPE _ ® I PRESSURE ® 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION LEI CCR§2636(a)(391111_-., ..... ._.______ ____. .._.._._. ......____ .. ____ _ _. _...._ _ - _. ._.. PRIMARY CONTAINMENT ❑ I.STEEL ® 4 FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE _❑ 95..UNKNOWN .__❑ 99.OTHER(Specify)_ 460.a SECONDARY C11 ONTAINMENT ❑ I STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 46'b ❑ 90 NONE _ _ ❑-0-1-SINGLE 95 UNKNOWN ❑ 99 OTHER(Specify)_ 46°c .._...".__-" _.. _. PIPINGlTURBINE CONTAINMENT SUMP TYPE ❑ 1 SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4a4d VI. VENT, VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify)' 46�e1 .. __. .. .. .__ _ ..._..__ _ 46nf VENT SECONDARY CONTAINMENT ❑ 1 STEEL ® 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spccsfv) 4640 " VR PRIMARY CONTAINMENT ❑ 1 S PEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify). 4ya4a� 464h VR SECONDARY CONTAINMENF ❑ 1 S I FEI. ® 4 FIBERGLASS ❑ IO.RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify) 4( hl VENT PIPING TRANSITION SUMP TYPE ❑ I SINGLE WALL C12.DOUBLE WALL ❑ 90 NONE 464 RISER PRIMARY CONTAINMENT ❑ I SIEEL ® 4 FIBERGLASS ❑ I D.RIGID PLASTIC ❑ 90.NONE ❑ 99 OTHER(Specify) _..... .. ___._. ...... _ ... 464k RISER SECONDARY CONTAIMMEN I ❑ I STEEL ❑ 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify) 464k FI _ _ __ LL COMPONENTS INST_AL ❑ 4 S LED ❑ I SPILL BUCKET TRIKER PLATGBOTTOM PROTECTOR ❑ 4 NI COAINMEN'I'SUMP VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ L SINGLE WALL R 2.DOUBLE WALL [j3.NO DISPENSERS C3 90 NONE 169s CONSTRUCTION MATERIAL ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 OTHER(Specify) 9 a6q<- VIII. CORROSION PROTECTION � c STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL.ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLA"PION u 448 IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this USIT system is compatible with the hazardous substance stored and that the information provided he cin is true, i ccura[ ands' fu 'c'onaqAnncVith I al re uirements. .APPLICANT SIGNATURE DATE 5/1/2010 46 471 APPLICANT TITLE 4n APPLICANT NAME(print) RUp1I1(ler Padda SeC