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04'LNIFIED PROGRAM CONSOLIDATED F 0 M UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per LIST) TYPE OF ACTION (Check one item only. For an UST petrument closure or removal,complete only this section and Sections I,II,IH,IV,and IX below) 430 E 1.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: 43081 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) .Z I ( ( � 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) •b 3 EAST HARNEY ARCOF 12 - T BUSINESS SITE ADDRESS 103 CITY 104 255 E.HARNEY LANE LODI IL TANK DESCRIPTION TANKID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THISTANK Is 434 ❑I.A STAND-ALONE TANK 2 TA 05205 3XERXES 0 2.ONE M A COMPARTMENTED UNIT. Complete one pW for each com atvamt iu the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 N/A 10, 000 2 III.TANK USE AND CONTENTS TANK USE 0 la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ la AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lacludm Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 425281.5(,)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 N 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : 4108 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 6406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL N 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL E 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7-STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4448 SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4458 OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS N 2.BALL FLOAT E 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE-WALLED E 2.DOUBLE-WALLED [199 OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(aX3)] 458 PRIMARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4648 SECONDARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ HL RIGIDPLASTIC 46 b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464, PIPINGfrURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL E 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL E 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464, 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL E 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E a64n VR PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 I VR SECONDARY CONTAINMENT ❑ L STEEL E 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT L STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464i 4641 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET E 3.STRIKER PLATE/BOTTOM PROTECTOR E4.CONTAINMENTSUMP 4518-e VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 0 2.DOABLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4698 CONSTRUCTION MATERIAL ❑ L STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) ¢._' 4698, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448, IX. APPLICANT SIGNATURE �-�- CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided Nn is true,accurate, and in full compliance with legal requirements. C"D APPLICANT SIGNATURE Y. DATE 2/25/13 470. APPLICANT NAME(print) 471. APPLICANT TITLE 472. Jonathan Ramos Design Engineer UPCF UST-B-1/2 J l'� Rev.(12/2007)