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03/02/2012 03:38 9252920074 GDF_SOLUTIONS FAX PAGE 11/15 NIFIED PROGRAM CONSOLIDATED UNDERGROUNII STORAGE TANK _ .I l 2' 5� 5 OPERATING PFJtY<1T APPLICATION--TANK WORMATION(one form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections L It.Ill,IV,and IX below) 4I0 ❑ 1,NEW PERMIT Q 3.RENEWAL PERMIT 0 5,CHANGE OF INFORMATION 6,TEMPORARY UST CLOSURE ❑ 7,UST PERMANENT CLOSURE ON SITE ❑ 9.UST REMOVAL DATE UST PERMANENTLY CLOSED; 430a I DATE EXISTING UST DISCOVERED: 430b L FAC JTY INFORMATION FACILITY W#(,4 Amoy Use 0+44'J _ t BUSINESS NAME(Same as FACILITY NAME or DHA-Doing Susirlm As) 3 Country Club 76 BUSINESS SITE ADDRESS 1v3 CITY 104 2575 Country Club 131vd. Stockton IL TANK DESClUMON TANK ID# 432 TANK MANUFACTURER, 433 TANK CONFIGURATION: THIS TANK IS 434 AO SMITH ISI I.AsTAND-AIANETANK _t ❑ 2.ONE IN A COMPARTMENTED UNIT. cmplcta ono ow For each a mtm in the mii DATE UST SYSTEM INS'T'ALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 01/01/2006 15000 1 TIL TANK USE AND CONTENTS TANK USE 0 1a.MOTOR VEHICLE FUELING ❑ 1 b.MARINA FUELING ❑ 1 c.AVIATION FUELING 439 ❑ 3.CH"CAL PRODUCT STORAGE ❑ 4,HAZARDOUS WASTE(Ihelud®Uacd oil) ❑ 5,t MERGENCY GENERATOR FUEL jHsc§23261,5(c)] ❑ 6.OTM GENERATOR FUEL ❑ 95,UNKNOWN ❑ 99.OTHER (Specify): 439a CO PETROLEUM: TSI la.REGULAR UNLEADED ❑ 1a MOGRADE UNLEADED ❑ 1b.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5,JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM 440a NON-PETROLEUM:❑ 7.US1 0 OIL E3 METHANOL tJ 11 OTHER NON-PMOLEUM(Spmift 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1-SML6 WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT El 1,STEEL 0 3.FIBERGLASS Q 6.INTERNAL BLADDER 444 7,STEEL 4 INTERNAL L(NTNO ❑ 95.UNKNOWN Q 99.OTHER ( ): 444a SECONDARY CONTAINMENT a 1,STEEL 113.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7,JACKETED 445 ❑ 90.NONC ❑ 95.UNKNOWN 1399.OTHEX( fw): 4456 OVERFILL PREV'8NTION 99 1.AUDI)31.11 dt VISUAL ALARMS ❑ 2,BALI,FLOAT N 3.FILL TU13E SIfUT-OFF VALVE 4$2 © 4.TANK MATS RZQt=EME•NTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTR Pfl1 vG CON9MUCTION PIPING CONSTRUCTION L SINGLE-WALLED 02.DOUBLE-WALL A 99.OTf>ER 460 SYSTEM TYPE 99 1.PRESSURE Q z,GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(2)4Ca§2636(613)1 458 PRIMARY CONTAINMENT ❑ 1.'STEEL TSI 4.F,IBSRGLASs ❑ S.FLEXIBLE ❑ lo.R1GID PLASTIC 464 Q 90.NONE ❑ 95.UNKNOWN ❑ 99,OTIIER(S fy): 4646 SF,CONDARY CONTAINMENT 0 I.STEEL. ® 4.FIFIE.ROLASS ❑ S.FLEXIBLE 1o•RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN C) 99,OTHER(Seal ). 46491 PIP114611LSBINE CONTAMM NT SUMP TYPE ❑ 1.SINGLE WALL ® 1 DOUBLE WALL ❑ 90.NONE 464d VL VENT,VAPOR RECOVERY )AND RISER/FILL,PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMt;NT EJ 1.STEEL 129 4,FIBERGLASS ❑ W.RIO10 PLASTIC ❑ 90.NONE 99,OTHER(Specify) 464c 464x! VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER MwillY) "Alf 4648 VR PRIMARY CONTArNhMU © 1.STEEL ® 4,FIBERGLASS 10,R.IOID PLASTIC 0 90.NONE 99.OT(dLR(Specify) 4645 !ell VR SECONOARY CONTAINMENT In 1.ST MI 4.FEERGLASS ❑ 10.RIGID PLAS"r1C El 90.NONE ❑ ".OTHER(Specify) 464h 46481 VENT PII-MG TRANSITION SUMPTYP! 0 1,SINGLE WALL 19 2.DOUBLE W 90.NONE 44Wi. RISER PRIMARY,CONTAINMENT 29 1.STEEL 0 4,9PERGLASS E3 10.RIGM PLASTIC U 90.NONE 0 99,OTHU(Spcoify) 44 RISER SECONDARY CONTAINMENT 1.STEEL C9 4.1`1690LASS 0 lo.mm PLASTIC El 9o.NONE 13 99,OTHER(SPxiry) 464k 464k1 FILL COMPONENTS INSTALLED I.SPILL BUCKET M 3.STMiK$R PLATEMY17TOM PROTECTOR 10 4,CONTAINMtENT SUMP 451" VII.MINDER DISMNSIR CONTAII00ENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL N 2,DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4696 CONSTRUCTION MATERIAL ❑ 1.STEEL Z 4.I MERGLASS ❑ lo.RIGID PLASTIC ❑ 99,OTHER 46 VUL CORROSION PROTHiMON STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 0 6.ISOLATION 44a, 1X APPLICANT SIGNATURE CERTIFICATION:1 certify that this UST system is compatible with the hazardous substance stored clad that the ktlbrmatton provided Rtrelm IN tram,atturste, and In foil ces6isate with legal requirtmeoM APPLIC GNAT'S jRE DA'T'E//v�. � 470 1,211) APPLICANT NAME r 47). APPLICA Thi 472 Mike Ahmadi ((print) r klp Dealer UPCF UST-8-I/3 Rev.(12/007)