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03/02/2012 03:38 9252920074 GDF_SOLUTIONS FAX PAGE 13115 Ah� 111111L ITNIFIED PROGRAM CONSOLIDATED FM •_ e:: UNDERGROUND STORAGE TANKG / (L 0� e OPTRATING PERMIT APPLICATION-TANK INFORMATION U.f�l> UST) LTYPEOPACTM (Check one item only. For an UST permanent closure or removal,complete only this seehon and Sections L,II,Ili,LV,and IX below) 470 ❑ 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: a700 1 DATE EXISTING UST DISCOVERED: 430D L FACILITY INFORMATION FACILITY ID 0(Agency Ux Onty) _ 1 BUSINESS NAMS(Scone as FACILITY NAME or DBA-Doing Busincss As) 3 Country Club 76 BUSINESS SITE ADDRESS 103 CITY 104 2575 gounq Club Blvd. Stocwn IL TANK DESCRIPTION TANK IDS 412 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 3-Diewl AO ShUTH ©1.A STAND-ALONE TANK ®2.ONE IN A COMPARTMENTED UNIT. camode ane fbr aNgi eom artMPt In the yntt DATE UST SYSTEM INSTALLED 435 TANK CAPACI fY IN GALLONS d36 NUMBER OF COMPARTMENTS IN THE UNIT 437 01/01/2006 70M 2 III.TANK USE AND CONTENTS TANK USE ® Ia.MOTOR VEHICLE FUELING © Ib.MARINA FUELING ❑ le,AVIATION FUELING q}9 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZA DOUS WASTE(1nchAts used oit) ❑ 5.EMERGENCY GENERATOR FUEL(HSC @5561 S(c)) ❑ 6.OTIMR GENERATOR FUEL ❑ 95.UNKNOWN Q 99.OTHERS ft 439a CONTENTS PMOLEUM; ❑ In.REGULAR UNLEADED ❑ Ic.MIDGRADEUNLEADED ❑ lb.PREMAUMUNLEADED O00 0 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL Q 9.07MR PMOUVM ( 440a NON-PMODUM:❑ 7.USt_ri OIL ❑ 10,)ETHANOL d 11.OTHER NON-PETROLEUMS i l: 440h IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLF.WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1,STEM ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 © 7.STEEL+INTERNAL)UNING 95.UNKNOWN ❑ 99,OTHER (S 444a SECONDARY CONTAINM W ❑ IISTM 0 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRAN'L LMR ❑ 7.JACKETED 445 Q 90.NONE ❑ 95,UNKNOWN ❑99.OTHER(Specii 445a OVERFILL PREVEEIMON IN 1.AUDMLE&VISUAL ALARMS M 2.BALL FLOAT 3.FILL,TUBE SHUT-OFF VALVE 4S3 ❑ 4.TANK MEETS REQUIR14NWNTS FOR lrx I[ON FROM OVERFILL.PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIA NG CONSTRUCTION 0 1.SINGLE-WALLED N 2.DQUaLE•WAL,LEO ❑99.OTHER 46D SYSTEM TYPE ® 1.PR965Sl= 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION J CCR Wa(a)(3)L 458 PRIMARY CONTAINMENT 0 1,STEEL IR 4_FIBERGLASS ❑ 9.FLEXIBLE 0 10.RIGID PLASTIC 464 ❑ 40.NONE ❑ 95.UNKNOWN ❑ 99,OTHER(S *{ 464, SECONDARY CONTAINMENT E3 1,STEEL N 4.FIBERGLASS ❑ S.FLEMBLE ❑ 10.RIGID PLASTIC 464s ❑ 90,NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4640 PIPINO/TURBINE CONTAINMSTIT SUMP TYPE Q 1,SINGLE WALL ® 2.DOUBLE WALL ❑ 40.NONE s644 VL VENT,VAPOR RRCOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINIhO NT Lj i.STEEL 29 4.FIBERGLASS ❑ 10.RIGID PLASTIC c3 90,NONE d 0.OTHER(Speciry) 4a4e 464e1 VENT SECONDARY CONTAINMENT 0 1.STEEL 19 4.MEMLASS Q 10.RIGID PLASTIC 0 90.NONE ❑ 99 OTHER(Spwlfy) 464r WA VR PRIMARY CONTAINMENT 0 1.STEEL. N 4.FIBLROLASS ❑ 10.RIGID PLASTIC 0 90.NONE [3 99.OTtmR(SpMify) 4648 46W VR SECONDARY CONTAINMENT 1.STII:L ® 4,FIBERGLASS 0 10_RIGID PLASTIC 0 90,NONE 0 99,OTHER(Specify) 464h 464111 VENT PI1?lIIiGTRANSIIION SUMP TYPE Q 1.SINGLE WALL IN 2.DOUBLE WALL Q 90,NONE 464;. !USER PRIMARY CONTAINMENT 29 1.STEEL ❑ 4.FIBERGLASS I0.RIGID PLASTIC 0 90.NONE Q 99.071111!(Specify) 464i 4641 S 1.STEEL 99 4.FIBERGLASS 0 ID.RIGID PLASTIC 0 90,NONE 99,OTHER(Spcciry) 464k 464Et FILL COMPONENTS INSTALLED 0 1.$PILL BUCKZT ® 3,STRIKER PLATEMOTTOM PROP ECTOR ® 4.CONTADWENT SUMP 451a•a VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 3,NO DASI*ENSERS ❑ 9o.NONE 4694 CONSTRUCTION MATMAL ❑ 1.STEEL. N 4.FIBERGLASE75 10.KIQW PLASTIC ❑ 99.OTI4ER(S i <av11ti VIII. CORROSION PROTI:MON STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 449 IX* APPLICANT SIGNATURE CERTIFICATION: I certify that 04 LIST system Is compatible with the Ittwrdous substance stored and that the Information provided herein is true*accurate, and in!bit P&Pliance with legal reguirements. APPLICA#f SIGNATURE, DATF 470 /'Q- APPLICANT NAME(prim) 471 APPLICANT TITLE Ort Mice Abmadi Dealer UPCF UST-S-2l3 F" Rev.(1247087)