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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 ® 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: 430b. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. CRLLC/76#5447 BUSINESS SITE ADDRESS 103. 1 CITY 104. 1469 E. Hammer Lane Stockton IL TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 1 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 12,068 III. TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ ]b.MARINA FUELING ❑ Ic.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 _ - [1 95.UNKNOWN__-- -- - ❑ 99:OTHER(Specify): 439a. CONTENTS PETROLEUM: ® I a.REGULAR UNLEADED ❑ 1 c.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS _._.-_.__..___......_........._._........_.____..._.._.-_.,.._..........._ 8.PETROLEUM BLEND FUEL - ❑ 9.OTHER PETROLEUM(Specify): 440x. 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 ❑ 95.UNKNOWN 743. PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. SECONDARY CONTAINMENT ❑ L STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ---------------- ---- --- -[_90_NONE 0_95.UNKNOWN------[99.OTHER(Specify): 445a. _. .. OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 752• 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 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§26_36(a)(3)] --458 PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ,- -..._._[1 90.NONE - - ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE a6aa. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER464e. (Specify): 464eL VENT SECONDARY CONTAINMENT ❑ 1.STEEL 1.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify):P fY): 4664f1.4M VR PRIMARY CONTAINMENT ❑ 1.STEEL [14.FIBERGLASS El 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER4648. .._. _ (Specify): 464 ]. VR SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS El10.RIGID PLASTIC ® 90.NONE El 99. eci 464h. ( P fyk 464h1. VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. It RISER PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify): g46ij; RISER SECONDARY CONTAINMENT ❑ 1.STEEL❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC- ® 90.NONE ❑ 99.OTHER(Speci _ 464k. fY) 464k1. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATEBOTTOM PROTECTOR --❑ 4.CONTAINMENT SUMP 45la-c. VII._ UNDER DISPENSER CONTAINMENT (UDC) \ CONSTRUCTION TYPE 1.SINGLE WALL 2.DOUBLE WALL 3_.NO DISPENSERS _ ❑ 90.NONE E 469a. CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ ---._......._..._._._._..._._._..._._.._.. ...----- ---- -- - -------------------------- -._._.__.._...---.._.. � 4696. 99.OTHER(Specify) 469c. VIII. 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,and in full compliance with legal requirements. APPLICANT SIGNATURE DATE / 470. APPLICANT NAME(print) Allen FaaSS 471. APPLICANT TITLE California Compliance Manager 472 UPCF UST-B Rev.(12/2007)-1/2 www.unidoes.org