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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION tone form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,11,111,IV,and IX below) 436 <br /> ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430a. 1 DATE EXISTING UST DISCOVERED: 4Mb <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) _ 1 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> Tracy Blvd Shell 136186 <br /> BUSINESS SITE ADDRESS 163. CITY 164 <br /> 3725 Tracy Blvd Trac <br /> IL TANK DESCRIPTION <br /> TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. <br /> ® 1•ASTAND-ALONE TANK C�1«e��ror�h <br /> 2-Plus Owens Coming <br /> ❑ 2.ONE IN A COMPARTMENTED UNIT computmem in the mut. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437• <br /> 5-22-1990 12,000 <br /> III. TANK USE AND CONTENTS <br /> TANK USE ® la MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(lodimles Used Oa) ❑ S.EMERGENCY GENERATOR FUEL(HSC§25281 5(c)) <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a <br /> CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ® le.MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ $.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 4400. <br /> NON-PETROLEUM:0 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM( cif): 440b. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a, <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. <br /> E3 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 4459. <br /> OVERFILL PREVENTION 19 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452 <br /> 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION 123 CCR§2636(9x3) 458. <br /> PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4649. <br /> SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 9.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(specifyy 464c. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464x. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS [310.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46 eel46 , <br /> VENT SECONDARY CONTAINMENT [3L STEEL ® 4.FIBERGLASS [310.RIGID PLASTIC [390.NONE [399.OTHER(Specify): 4664fl <br /> VR PRIMARY CONTAINMENT C] L STEEL ® 4.FIBERGLASS (310.RIGID PLASTIC [390.NONE (399.OTHER(Specify): 4�g' <br /> VR SECONDARY CONTAINMENT [3L STEEL® 4.FIBERGLASS [310.RIGID PLASTIC [190.NONE [399.OTHER(Specify): <br /> 464 j, <br /> VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 49 <br /> RISER PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q4" <br /> RISER SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46 kU <br /> FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEIBOTPOM PROTECTOR IM 4.CONTAINMENT SUMP 451ac. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4698. <br /> CONSTRUCTION MATERIAL ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469C. <br /> VIII. CORROSION PROTECnON <br /> STEEL COMPONENT PROTECTION E3 2.SACRIFICIAL ANOD S) ❑ 4.IMPRESSED CURRENT 0 6.1 LATION 448, <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true. <br /> accurate,and in full compliance with legal r uirements. <br /> APPLICANT SIGNATURE DATE 7/19/2010 476. <br /> APPLICANT NAME(print) Fadi Afa Al-Refaee 471 APPLICANT TITLE Agent for Owner 4n <br /> UPCF UST-B Rev.(1212007)-1/2 www.unidocsorg <br />