Laserfiche WebLink
01 <br /> qZ <br /> U X3140 <br /> UN r ED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1, 11,//1.IV.and 1, below) 030 <br /> ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED', 630a DATE EXISTING UST DISCOVERED: 430, <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) - 3 <br /> George's Mini Mart eo <br /> BUSINESS SITE ADDRESS 103 CITY <br /> 18662 N HWY 88 LOCKEFORD <br /> II. TANK DESCRIPTION <br /> TANK ID# 2 TANK MANUFACTURER d31 TANK CONFIGURATION:THIS TANK IS 430 <br /> T S t e t,2g TRUSCO ❑ I.A STAND-ALONE TANK Complete one page ror sh <br /> ® 2.ONE IN A COMPARTMENTED UNIT companm i in the unn <br /> DATE UST SYSTEM INSTALLED 43$ TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UN 11 431 <br /> 05-28-1995 6,000 2 <br /> III. TANK USE AND CONTENTS <br /> TANK USE 0 la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 4'0 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includa Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281_i(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 419.. <br /> _._-.. --' -_-__.._ _.....__-_._..----- --`---'----.- --- ' ----PREMI <br /> CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ® Ic.MIDGRADE UNLEADED ❑ Ib PREMIUM UNLEADED <br /> ❑ 3.DIESEL ❑ 5.YET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM.(Specify). 44oa.. <br /> ..---SE.ED OIL _.-......_..__ 10 _ <br /> NON-PETROLEUM ❑ 7.U ❑ .ETHANOL <br /> ❑ 11.OTT ER NON PETROLEUM Specify): <br /> 4a9b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ I SINGLF WALL ® 2 DOUBLE WALL ❑ 95 UNKNOWN 443 <br /> . . _ .. __ .._.. 444 . <br /> PRIMARYCONI-AINMFNT [DI STEEL. ® 3.FIBERGLASS ❑ G.IN-I RNAL BLADDER <br /> ❑ 7 STEEL'INTERNAL LINING C] 95 UNKNOWN ❑ 99 OTHER(Spec,fy), J44a <br /> SECONDARY CONTAINMENT ❑ I STEEL ® IB <br /> 3 FERGLASS C16.EXTERIOR MEMBRANE LINER El 7.JACKETED 44S <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99 OTHER(Specify): 445a. <br /> .._- ....___._ _..__._. .___.._.._.. 452 <br /> OVERFILL PREVENTION ® L AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ® }.FILL TUBE SHUT-OFF VALVE <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT <br /> V. PRODUCT /WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 99 OTHER 4&1 <br /> ...__- _ _.__. . . -_ __..- 4s8 <br /> _SYSTEM TYPE_ ® I PRESSURE ❑ 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4 SAPS SUCTION[v cca pz686(ari3)I <br /> ___- _ __._ .__.___...._ _......_ 464.... <br /> PRIMARY CONTA_NMENT ❑ I.STEEL ® 4 FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC <br /> ❑ 90.NONE [j95 UNKNOWN ❑ 99 OTHER(Specify):- a604 <br /> -._...E .. . ___--_-- "-_-_- .__ <br /> S . 6ab_ <br /> CONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8 FLEXIBLE ❑ 10.RIGID PLASTIC 4 <br /> ❑ 90 NONE ❑ 95 UNKNOWN ❑ 99 OTHER(Specify): 06e._. <br /> PIPINGIfORBINE CONTAINMENT SUMP TYPE ❑ I SINGLE WALL ❑ 2 DOUBLE WALL ❑ 90.NONE 4a4d-- <br /> VI. VENT,VAPOR RECOVERY (VR) AND RISER/ FILL PIPE PIPING CONSTRUCTION <br /> 464c <br /> VENT PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90,NONE El 99.OTHER(Specify)'. <64el.. <br /> TMIF <br /> VENT SECONDARY CONTAINMENT ❑ 1 STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99 OTHER(Spec,fv)� 4640 <br /> ...__._._ .-....___ __.... p ... <br /> VR PRIMARY CONTAINMENT ❑ I STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.01 HER(S eafy). 4u e_, <br /> e <br /> .........._ _._. .___.__ __._..-.. .._.......__.. -......_.__ awn. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify)'. 46 hl <br /> ._.._.. ..____ .___-_.. .__. -..- 4641.. <br /> VENT PIPING TRANSITION SUMP TYPE ❑ I SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE <br /> ......._... ".._.__- ..-....._._. __ .___ .____ _____ 4wt._ <br /> RISER PRIMARY CONTAINMENT ❑ I STEEL ® 4 FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify) 464j1._. <br /> RISER SECONDARY CONTAINMENT ❑ 1 STEEL El FIBERGLASS El 10,RIGID PLASTIC [_190 NONF El 99 Ol HER(Specify). 4Mkl <br /> FILL COMPONENTS INSTALLED ❑ I SPILL BUCKET ❑ 3 STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451 a-< <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPE ❑ I.SINGLE WALL - ®-2.DOUBLE WALL ❑ 3.NO DISPENSERS JI 90.NONE //►���� n69a <br /> ...._._ ............. .._ ._.-._ .__-....-__._ _-.....__T_--..___ .-_.__-_..-_.___ ______- ___CZ0 4L9b_. <br /> CONSTRUCTION MATERIAL ❑ 1.STEEL J�L 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 OTHER(Specify) 469c. <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION El 2.SACRIFICIAL ANODE(S) [14.IMPRESSED CURRENT ❑ 6.ISOLATION 448 <br /> IX. APPLICANT SIGNATURE Ej <br /> CERTIFICA I'ION: I certify t#thisT system is compatible with hazardous substance stored and that the information provided herein is true. <br /> accur te,ali ce with le al re u' encs. <br /> APPLICANT SIGNATURE DATE 5/1/2010 <br /> APPLICANT NAME rint) 4'1APPLICANT TITLE SeC 4)2 <br /> (P RPadda <br />