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WRFIED PROGRAM CONSOLIDATED FOW 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 1, 11, 111, IV, and 1X below) 430. ❑ 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: 430x. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 1=1010101-1 1_1-_451Z .11 L BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. 7 -Eleven # 20632 BUSINESS SITE ADDRESS 103. 1 CITY 104. 4627 DaVinci Dr. Stockton IL TANK DESCRIPTION TANK ID # �"� `, �� 32 TANK MANUFACTURER 433• TANK CONFIGURATION: THIS TANK IS 434• 001 5y Total Containment ® 1. A STAND-ALONE TANK Complete one page for each ❑ 2. ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435• TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 4/1998 10.000 III. TANK USE AND CONTENTS` TANK USE ® la. MOTOR VEHICLE FUELING ❑ lb. 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. OTHERS cif 439a. .................................................................. CONTENTS PE, TROLEUAD M: ® la. REGULAR UNLEED ❑ lc. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED• ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ................................................................. -.._........_. ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440a. _.........................._....................................-..........................................................................................------.._.._.......__........_...._.._.. ................ ..........._.... ........ _..... NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL LJ 11. OTHER NON -PETROLEUM (S ecif ): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1 SINGLE WALL ® 2. DOUBLE WALL ❑ 95. UNKNOWN 443• ...................................................................................................................................._._.._...__......_._..........................................................................................................................._....................................._............................................... PRIMARY CONTAINMENT ® 1. STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444• - ..........._❑....7. STEEL + INTERNAL LINING ❑...-95. UNKNOWN ❑ 99. OTHER (Specify): 444a. SECONDARY CONTAINMENT ❑ 1SEL . TE..................................GA ❑ 3. FIBERLSS ❑ XTEOMBN 6. ERIR MERAE LINER.............®...45: .7. JACKETED 4..... ❑ 90. NONE ❑ 95. UNKNOWN [199. OTHER (Specify): 445a. OVERFII L PREVENTION -_..__......® 1. AUDIBLE &VIS, UAL ALARMS ❑ 2. BALL FLOAT _......_.. -.___.._..___0 3. FILL TUBE SHUT-OFF VALVE ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT V. " PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION❑ 1 SINGLE WALL ® 2. DOUBLE WALL ❑ 99. OTHER 460. ..............................................................._...................................._. - - SYSTEM TYPE ® 1: PRESSURE 0 2. GRAVITY ❑ 3: CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)] 458. ................... ... .................... PRIMARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ® 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464a. SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4"--F-,l BERGLASS ® 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑..._90.:._NONE 95 99. OTHER (Specify):...... 464c. ..............................._0..._ EN.:._UNKNOWN............. -[ P�INGlrURBINE CONTAINMT SUMP TYPE ® 1. SINGLE WALL [32. DOUBLE WALL ❑ 90. NONE 4 VI. VENT, VAPOR; RECOVERY (VR)' AND RISER/ FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I STEEL ® 4. FIBERGLASS ❑ ]0. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): ......................... ...................................................... ..... 4464. _........ VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): ) ....................... 464C 46411. . VR PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): ..............................................................................................................................................._......---................................................................................................................................................................................._......................................................_. ....................... 4644g. G.......... VR SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): ' 464h.y 464hl. VENT PIPING TRANSITION SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE ................ _............................................................................... _.............................................................................................. 464'. RISER PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): __..........-................................................................................................................................................................................__........................................_.............._......_.._...............................................__.._.._..__............................................................................................................................................... 4641 ..........J.......... RISER SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER . (Specify): ......... y .............................................................................................................................................................. 464k. 464U FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER° CONTAINMENT (UDC) CONSTRUCTION TYPE ®1 SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE ..................................................................................._................_...._._ ........------.......................................................................................... 469a. _.................... ..... ............................................................................... -------.._.................... ......................................... ............................................................... ..................................... CONSTRUCTION MATERIAL ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) ' , . 469b. VIII.CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION ,,3 448• IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information " v 4*d herein is true, accurate and in full compliance with legal requirements. ,; IL ;� APPLICANT SIGNATURE DATE 470. APPLICANT NAME (print) Ian Moorhead 471 APPLICANT TITLE Env. Compliance 472. UrUt LIN '1-B Kev. (1212OU7) - 1/2 www.unidocs.org