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of AL • n SiI•t.0 UN TIED PROGRAM CONSOLIDATED FOR011W UNDERGROUND STORAGE TANK 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, 114 1V,and 1X belo}v) 430 ❑ 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'. 4304 1 DATE EXISTING LIST DISCOVERED 430b I. FACILITY INFORMATION FACILITY ID H(Agency Use Only) - - BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) ' George's Mini Mart BUSINESS SITE ADDRESS 103 CITY 10° 18662 N HWY 88 LOCKEFORD II. TANK DESCRIPTION TANK IDH si? TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS d14 C1ge Poea L A STAND-ALONE TANK Complete one par ch TRUSCO ® 2.ONE IN A COMPARTMENTED UNIT companmeni in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 037 05-28-1995, 4,000 2 III. TANK USE AND CONTENTS TANK USE E N.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING a39 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ineledes U.M Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252815(c)) ❑ 6 OTHER,GENERATOR FUEL _❑ 95.UNKNOWN __ El 99,OTHER(Specify). 43% CONTENTSPETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic MID(-RADE UNLEADED ® Ib PREMIUM UNLEADED 440 C3 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL,„ [:19 OTHER PETROLEUM.(Specify): 440.. NON PETRLE OUM ❑ 7.USED OIL ❑ 10 ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify). 4401, IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1SINGLE WALL E 2 DOUBLE WALL ❑ 95 UNKNOWN .._. 043 _.___ ._. _.-.-.. __...___ IE__- ..____ . ... ..........._ _._....___ -___.._. ..__ - _ PRIMARY CONTAINMENT ❑ I.STEEL ® 1 FIBERGLASS ❑ 6.INTERNAL BLADDER 440 ❑ 7.STEEL INTERNAL LINING El 95.UNKNOWN El 99.OTHER(Specify) 444a ___..... .. ..__-...._ _ .._..._...-_ _...__.__..... _ _. __.... _. . SECONDARY CONTAINMENT ❑ I STEEL E 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 0,90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): OVERFILL PREVENTION ® I.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS RE UIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT /WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I.SINGLE WALL. E 2.DOUBLE WALL ❑ 99 OTHER d00 ..-.. - - __.__. - _.__ .___.._ ... _..S SYSTEM TYPE ® L PRESSURE ❑ 2 GRAVITY ❑ 3.CONVENTIONAL SUCTION_ ❑ 4 SAFE SUCTION 123,CCa S2636(a)(311 45$ PRIMARY CONTAINMENT ❑ STEEL E 4.FIBERGLASS ElS.FLEXIBLE ❑ 10.RIGID PLASTIC °6J I. SECONDARY CONTAIN ❑ 90-NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify) 964e .. __- __. __.._._-._.__...__..__.___.. ....... _.... MENT ❑ I STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 95.UNKNOWN _❑ 99 OTHER(S.Ne,N)'. 46°c' PIPING/TURBINE CONTAINMENT SUMP TYPE [II SINGLE WALL F12.DOUBLE WALL - ❑ 90.NONE 464x_- VI. VENT, VAPOR RECOVERY (VR) AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL E 4.FIBERGLASS [310.RIGID PLASTIC El 90 NONE El 99.OTHER(Specify). qb� _ 464r VENT SECONDARY CONTAINMENT ❑ I STEEL ® 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specdv): 46lt7 \'R PRIMAR)'CONTAINMENT ❑ 1 STEEL E 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify). q°6d645u .......... _....._. _.. _. _._ .. .... . 464h. R SECONDARY CONTAINMENT ❑ I S'IEEL E 4 FIBERGLASS ❑ 10.RIGID PLASFIC ❑ 90.NONE ❑ 99 OTHER(Specify) 464hl 464,_. \'ENT PIPING TRANSITION SUMP TYPE ❑ 1 SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE RISER PRIMARY CONTAINMENT ❑ I STEEL E 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464jt_ 4Wk RISER SECONDARY CONTAINMENT ❑ I STEEL ❑ 4 171BERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify), 464kl FILL COMPONENTS INSTALLED ❑ I SPILL BUCKEI ❑ 3 STRIKER PLATE/130170 M PROTECTOR ❑ 4.CONTAINMENT SUM 451.-c. VII. UNDER DISPENSER CONTAINMENT (UDC) M CONSTRUCTION TYPE ❑ 1.SINGLE WALL. E 2 DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90 NONI!®,aal 46911. CONSTRUCTION MATERIAL ❑ I STEEL K 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99 Ol HER(Spec'm 469c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION °4a IX. APPLI ANT SIGNATURE CERTIFICATION: I certify fan T sy tem is compatible th [he hazardous substance stored and [hal the information provid rein is true. accurate, m anec with le al uirements. 0APPLICANT SIGNATURE DATE S/l/ZOlO LZJAPPLICANT NAME(print) 071 APPLICANT TITLE See472 Padda