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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK Nt. 4, ; 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 ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 4306. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. CRLLC #2705447 BUSINESS SITE ADDRESS 103. CITY 104. 1469 E. Hammer Lane I Stockton IL. TANKDESCRIPTION TANK ID# TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. ~f i j '•, , Unknown ® 1.A STAND-ALONE TANK Complete one page for each ❑ 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. 3/31/1998 10,563 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)l ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. _........ .. _..__....._ _ ..... - ... CONTENTS PETROLEUM. ❑ la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ Ib.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): 4406. IV. TANK CONSTRUCTION TYPE OF TANK1 SINGLE WALL ® 2 DOUBLE WALL ❑ 95 UNKNOWN 443. ME PRIMARY CONTAINNT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. 7.STEEL+INTERNAL LINING E] 95.UNKNOWN 99.OTHER(Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): aa5a ... .....I. ..... .... _._.... OVERFILL PREVENTION ❑ 1 AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ZZ,3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL`PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION �11❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 99.OTHER 460. _ _ ...... SYSTEM TYPE a l PRESSURE ❑ 2 GRAVITY _ ❑_3 CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] as8. PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a _..___.._.1.11.._.1.._11111-111---l",__1.1.._.__.-....._...._....._-____...__..._....__.....__..._..___..._._.._..._.__._....__....__..._.___....__....__.._._.._.....-..-_.....__. _. SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC a6ab. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c _ .... 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 ❑ 90.NONE ❑ 99.OTHERS eci 4644. '1111_.... 1111.. ......._... __.._...__ ............._ ..._..... ...__... ......__....... .._........... ..._....___ 1111 .._..._... 11.11__.. 1111 ........._... _.,,,,, (Specify): 46441. VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ l0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46411; _11....11 .. -..__.._...... .. 1111.... ...............-_.._ ...............11 --. 1111... 1111. _...__. .. 1111.. _....__. 1111._ 1111_ VR PRIMARY CONTAINMENT ❑ L STEEL W4.FIBERGLASS ❑ 10.RIGID PLASTIC'-®.90.NONE ❑ 99.OTHER(Specify): 4648 _ 1111._- -._ 1111_ 64.._.... _......._....._. _........ .....___..._. 1111_ 11.11_ 1111 ...__._.__1111._ 1111.. .1111.. 464h. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464h1. - ...-_._....._....._ .._....._.__._.... ----..._....._....._...._._..........-......._....._....._.... ..._.....-..._....._....._....�__..._......__...----.-._-.__.....-..._......_...-.__....._......_....._._..._....._..__ __...._... ...._.... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464` ....... ..... _ RISER PRIMARY CONTAINMENT w 1.STEEL E] 4.FIBERGLASS ❑ 10 RIGID PLASTIC Pft,90.NONE ❑ 99 OTHER(Specify) 4641: 11.11__.._...�... --__..._...._... RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE r] 99.OTHER(Specify): 4664Mk1. _-.._..___.._...._......_..__..._..._...1111..._-1111_.-_.-.-..._.._..�a� _-�_____�.___....._..._.___...-_...__....._.....__..._..._._..__.._..._..__.. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET a 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 _.. _....._._..__....._. ....._.....__.._........_...__....-- _.._.__...---....._...__...__..__._........_.....__..__....._....._....._.... ...__....._....._.....__....__...._.....--- 4696. CONSTRUCTION MATERIAL 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469c. VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 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,an 'n full com ' e al requirements. APPLICANT SIGNATURE DATE 1 05 ago. APPLICANT NAME(print) Armen MkAyAian 471 APPLICANT TITLE California Compliance Manager 472 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org