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ft AML Ufflh4ED PROGRAM CONSOLIDATED FORW 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, 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: 430L DATE EXISTING UST DISCOVERED: 430b. I. FA►t T5 1.' ON . . FACILITY ID # (Agency Use Only) _ _ L BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. One Stop Market BUSINESS SITE ADDRESS 103. 1151 W. Louis Ave CITY 104. Mateca IL TANK DESCRIPTION TANK ID # `� o d 432. "2 TANK MANUFACTURER 433. UK TANK CONFIGURATION: THIS TANK IS asa. N 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. l2 - 'L' TANK CAPACITY IN GALLONS 436. 10,000 NUMBER OF COMPARTMENTS IN THE UNIT 437. 0 IiI. TANK USE AND CONTENTS TANK USE N la. MOTOR VEHICLE FUELING ❑ lb. 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 ❑ 95. UNKNOWN 99. (Specify): 439a _❑ _OTHER CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ Ic. 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 -PETROLEUMS ify): "Ob. IV. TANK CUN'I'Rt7'IC3N TYPE OF TANK ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 95. UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1. STEEL NJ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444. ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a. SECONDARY CONTAINMENT ❑ 1. STEEL ® 3. FIBERGLASS 0�6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED u 445- ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99- OTHER (Specify): 445x. OVERFILL PREVENTION ® 1. AUDIBLE & VISUAL ALARMS N 2. BALL FLOAT ❑ 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT `/ WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ L SINGLE WALL ® 2. DOUBLE WALL ❑ 99.OTHER_ 460. SYSTEM TYPE ® 1. PRESSURE ❑ 2. GRAVITY P_ [13. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTIO_N_3 CCR §2636(ax3)] 458. _C2 _ PRIMARY CONTAINMENT ❑ L STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464. 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 46U _❑ _ SECONDARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99- OTHER (Specify): 464c. PIPINGI TURBINE CONTAINMENT SUMP TYPE ®i. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d VI.VENT,VA1"QR ICOVERY R) -RISER / FILL PIPE PIPING CUNS''IIUCT'ION VENT PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4661. VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): 46444 VR PRIMARY CONTAINMENT T ❑ 1. STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC [190. NONE [199.OTHER (Specify): 464464 B. 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 4i RISER PRIMARY CONTAINMENT ® 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): a641i. RISER SECONDARY CONTAINMENT ❑ 1. STEEL [14. FIBERGLASS [110. RIGID PLASTIC ® 90. NONE [199.OTHER (Specify): 464k1. FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c. V11. UNDER DISPENSER CONTAINMEN'] ;"C) CONSTRUCTION TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a. CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4. FIBERGLASS ® 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4 7 469c. '4rIIi. coPROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANDD 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 SIGNATUREly " a DATE - Z 470. APPLICANT NAME (print) ffaTi Ka nboj 471. APPLICANT TITLE Partner 472. UPCF UST -B Rev. (12/2007) -1/2 v✓ww.unidocLorg