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wIFIED PROGRAM CONSOLIDATED F.,_�44 UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one forint er UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,[I,III,N,and IX below) 430 X 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 430b DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION I FACILITY ID#(Agency Use Only) 11 - 11 1 I - IT BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) Circle K#2701205 IN BUSINESS SITE ADDRESS I°3 CITY 16470 Cambridge Drive77f 17111110 N Lathro IL TANK DESCRIPTION TANK IDk432 TANK MANUFACTURER a33 TANK CONFIGURATION: THIS TANK IS 334 Unknown X 1.A STAND-ALONE TANK 2 ❑ 2.ONE INA COMPARTMENTED UNIT. Com Mme mw for mch com min dm mR. DATE UST SYSTEM INSTALLED 415 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 937 Unknown 10,000 1 UI.TANK USE AND CONTENTS TANK USE x la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ la AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Gip ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25291.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify: 439. CONTENTS PETROLEUM: ❑la REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED . 1b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.]ET FUEL ❑ &AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (S ify): ad°. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ I1.OTHER NON-PETROLEUMS c1' : 44M IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL x 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL X 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S c' : 444° SECONDARY CONTAINMENT ❑ 1.STEEL X 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ff 7.JACKETED 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_ ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION x I.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE x 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(s)(3)] 459 PRIMARY CONTAINMENT ❑ L STEEL X 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER($ ify): 464° SECONDARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS ❑ &FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINCIT IR.1 1BINE CONTAINMENT SUMP TYPE [IL SINGLE WALL Ll 2.DOUBLE WALL ❑ 90.NONE 464E VI VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE'PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) a64f a6/n VR PR04ARY CONTAINMENT ❑ L STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) a64g 466 I VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10.RIGID PLASTIC x 90.NONE ❑ 99.OTHER(Specify) 46/h 464hI VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL x 2.DOUBLE WALL 90.NONE 4641 RISER PRIMARY CONTAINMENT ❑ I.STEEL . 4.FIBERGLASS 10.RIGIDPLASTIC ❑ 90.NONE 99.OTHER(Specify) 4Z1' RISER SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC x 90.NONE 0 99.OTHER(Specify) 464k 4 Ikl FILL COMPONENTS INSTALLED x I.SPILL BUCKET x 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENTSUMP 451.< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE x I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATERIAL ❑ I.STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 449. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE � DATE 410 APPLICANT NAME(print) Dulcinea Covan 401' APPLICANT TITLE Compliance Manager 47 2 UPCF UST-B-1/1 Rev.(12/2007)