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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 an UST permanent closure or removal, complete only this section and Sections I, 11, 111, 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: 4304 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 Grant Line Shell BUSINESS SITE ADDRESS 107 2375 W. Grant Line Road CITY 104 Trac IL TANK DESCRIPTION TANK ID # 432 .2 PillsXerxes K v �J TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ® 1. A STAND-ALONE TANK ❑ 2. ONE M A COMPARTMENTED UNIT. Complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 1991 TANK CAPACITY M GALLONS 436 12000 NUMBER OF COMPARTMENTS M THE UNIT 437 III. TANK USE AND CONTENTS TANK USE 0 la. MOTOR VE111CLE FUELING ❑ lb. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Usod Oil) ❑ 5. EMERGENCY GENERATOR FUEL IHSC §25281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ ]a, REGULAR UNLEADED ® lc, MlDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 4400 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 443 PRRv1ARY CONTAINMENT ❑ 1. STEEL N 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99.OTIER (Specify): 444a SECONDARY CONTAINMENT ❑ I. STEEL 29 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 eci : 4454 ❑ 90, NONE ❑ 95. UNKNOWN [199. OTHER(Specify)' OVERFILL PREVENTION 1. AUDIBLE & VISUAL ALARMS ❑ 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 ❑ 1. SINGLE -WALLED ® 2, DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE ® 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(4)(3) 458 PRIMARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.071IIER(S ecify): 464a SECONDARY CONTAINMENT ❑ 1. STEEL ® 4. FIBERGLASS El 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER (Specify): 464o PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d VI. VENT; VAPOR RECOVERY (VR):'AND RISER./ FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ ].STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 0 1. STEEL ® 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE ❑ 99. OTHER (Specify) 464f 46411 VR PRIMARY CONTAINMENT ❑ I. STBEL 0 4. FIBERGLASS 10. RIGID PLASTIC 90. NONE 0 99. OTHER (Specify) 4648 464stl VR SECONDARY CONTAINMENT 1. STEEL N 4. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE 99, OTHER (Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE R 1. SINGLE WALL Q 2, DOUBLE WALL 90. NONE 4641• RISER PRIMARY CONTAINMENT N 1. STEEL ❑ 4. FIBERGLASS El 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641 464j] RISER SECONDARY CONTAINMENT ❑ 1. STEEL 0 4. FMERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1. SPILL BUCKET 0 3, STRIKER PLATE/BOTTOM PROTECTOR ® 4. CONTAINMENT SUMP 451s -c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE. ® 1. SINGLE WALL ❑ 2, DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 4694 CONSTRUCTION MATERIAL ❑ 1. STEEL ® 4. FMEROLASS ❑ 10. RIGIDPLASTIC ❑ 99.OTIIER S eci 469b -c VIII. CORROSION PROTECTION ""'° STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) [14. IMPRESSED CURRENT ® 6. ISOLATION 448. IX. APPLICANT SIGNATURE =7 4s CERTIFICATIO I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is tru4accurate, and in full compliance -with legal requirements. APPLICANT S1 ATURE A Ix", APPLi 01 471.ALE DATE 4 470' 1/27/2011 ' °" LE 472. i� neer UPCF UST -B - 1/4 Rev. (12/2007)