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at Sit-k U, 'IED PROGRAM CONSOLIDATED FORT UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One fort per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11. 1/1. 1V,and IA'below) e o ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430` DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID 9(Agency Use Only) _ _ I. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) - J George's Mini Mart BUSINESS SITE ADDRESS 103 CITY 104 18662 N HWY 88 LOCKEFORD II. TANK DESCRIPTION TANK ID 4 43 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434 TRUSCO ® 1,A STAND-ALONE TANK Comvlem one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT wmpanment in the unit. DATE UST SYSTEM INSTALLED 435- TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT a10 05-28-1995 10,000 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ la AVIATION FUELING ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used 010 ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252815(c)) ❑ 6.OTHER GENERATOR FUEL ❑ 95;;UNKNOWN ❑ 99.OTHER(Specify): 439.. CONTENTS PETROLEUM. ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ® 3 DIESEL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify) 440a NONPETROI,EUM I❑ ].USED OIL ❑ 10 ETHANOL ❑ I I.OTHER NON-PETROLEUM(Spcity): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL ® T FIBERGLASS ❑ 6.INTERNAL BLADDER 444 - __ _ __,__ ❑ 7 STEEL INTERNAL LINING_ ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a SECONDARY CONTAINMENT ❑ I STEEL ®3.PIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7 IACKETED 445 - ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(_Specify): 445. OVERFILL PREVENTION ® I.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452 ❑ C 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 ® I.PRESSURE ❑ 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION 1u CCR 526JNaNAI 458 .__ ....__ __._-_._ .-__..-.8 ........ PRIMARY CONTAMMT<NT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8 FLEXIBLE ❑ 10 RIGID PLASTIC 464 ❑ 90.NONE _. ❑ 95 UNKNOWN ❑ 99 OTHER(Specify): 464. SECONDARY CONTAINMENT OT STEEL 04.FIBERGLASS 0.8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 _ ❑ 90 NONE ❑ 95 UNKNOWN 099 O fHER(Specify),,,., 4Mc PfPING/TUIN RBE CONTAINMENT SUMP TYPE_ ❑ I SINGLE WALL ❑-2.DOUBLE WALL ❑ 90.NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT C1 I.STEFI. ® 4.FIBERGLASS ❑ ID.RIGID PLASTIC ❑ 90.NONE C199.OTHER(SP ecify). a60e 46`1 VENF SECONDARY CONTAINMENT ❑ I STEEL ® 4 FIBERGLASS ❑ 10 RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHERISpcafy).. 446f- .._ ___ .._._.. ....-_.-.._.... _ _.-__..... ------- 4641). VR PRIMARI'CONTAINMENT ❑ I STEEL ® 4 FIBERGLASS ❑ IO.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Spec,ly). 464g- _.. -0 _ _ ___ _ VR SECONDARY CONTAINMENT ❑ I.STEEL ® 4 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): a64h -_.._.._ i..... VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL [12.DOUBLE WALL ❑ no.NONE 464 ❑ 1 STEEL ® 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify) 446 1 RISER PRIMARY CONTAINMENT -- 4641 RISER SECONDARY CONTAINMENT ❑ 1 STEEL C14 FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify). 49w461:k FILL COMPONENTS INSTALLED ❑ I SPILL BUCKET ❑ J STRIKER PLATEMOTTOM PROTECTOR ❑ 4.CONTAINMENTSUMP 4a)s< VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1 SINGLE WALL ®-2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90 NON O.- 469n __._ _.......__ 0-1. ....-..._____-' . 4b�e_.. CONSTRUCTION MATERIAL ❑ I STEEL ❑ 4 FIBERGLASS ❑ IO.RIGIDPLASTIC ❑ 99 OTHER(Specify) s 460c. VIII. CORROSION PROTECTION STEEL COMPONENT P OTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION EE 448in . IX. APPLICANT SIGNATUREy CERTIFICATION: I certify [hall t s UST s tem is compatible with the hazardous substance stored and that the information provided rein is true, accura n full C, a e 'th le re uirements. APPLICANTSIGNATURE ) DATE 5/1/2010 itj 470. APPLICANT NAME(Print) Rupnder 6dda 971 APPLICANTTITLE See 472