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• >C/ /L� UNIFIED PROGRAM CONSOLIDATED FORM 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 I,II,III,IV,and IX below) 430. ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® S.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a 1 DATE EXISTING UST DISCOVERED: 43W I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. CRLLC#2705448 BUSINESS SITE ADDRESS 103. 1 CITY 104. 3202 W. Hammer Lane Stockton IL TANK DESCRIPTION TANK ID# t 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. M 1.A STAND-ALONE TANK Complete one page for each Unknown ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the wit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 12/19/1998 10,008 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ® 1b.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL [195.UNKNOWN 443. PRIMARY CONTAINMENT ❑ L STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+_ INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99 OTHER(Specify): 445a .......... .... _......._ OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 2'3.FILL TUBE SHUT-OFF VALVE 452. lik,l.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERF L PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1 SINGLE WALL 2 DOUBLE WALL ❑ 99.OTHER 460. SYSTEM TYPE �1.PRESSURE 2 GRAVITY ❑ 3 CONVENTIONAL_SUCTION_ ❑ 4.SAFE SUCTION[23 CCR§2636(ax3)] 458. PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC arab. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464°. ..... _...... ... .. _..__ .... PIPING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4644. VI.. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC [390.NONE ❑ 99.OTHER(Specify): 464ei. _............. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464fI _ _.._...... _... . VR PRIMARY CONTAINMENT ❑ 1 STEEL �4.FIBERGLASS ❑ 10.RIGID PLASTIC 90 NONE ❑ 99 OTHER(Specify): 4664gi. ...... . . ..... - _. ..._... - __ ... .. ...._ ... VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464h). _ _......._......-...........__....._....._.....__.,..--..._....__..._..__.... .__............._....._...._.....__.._-............_..........._...._.....-....._....._....._..._..........__..._....._...._....._...... - ....._....._--.._._._....._.....-....._....._....-..-._._..._...._....... .. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464i.- .... _......._ - __ 464]. RISER PRIMARY CONTAINMENT Aa 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0.NONE ❑ 99.OTHER(Specify): 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464kl. __..._-..............-_..._..._..... _...__.._... ..._....._._.__._...__..-... - ..-_...._.__.___-.._.._...._._._..._.-.._.. ..._....._....._____._....__...____-_.___ _.._.__.. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET IQ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL 3.NO DISPENSERS ❑ 90.NONE 469a. __..._.............._...._......_... ..._......_._.__.....__..__.............._...........__... ......._.._.__...... ......_......__....__-..._......_._..._..... ..._....._..�_._....____..._......_.. _._....._..__....._......._..._........_....._._...._............_....._......_.....__.....__....._._...._.....----- 469. CONSTRUCTION MATERIAL I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 99.OTHER(Specify) 469c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448, 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 com liars a uirements. APPLICANT SIGNATURE DATE 470 APPLICANT NAME(print) Armen Mkrtychian 471' APPLICANT TITLE California Compliance Manager 472 UPCF UST-13 Rev.(12/2007)-1/2 www.unidoes.org