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A) 1A01 FIED PROGRAM CONSOLIDATED F a UNDERGROUND STORAGE TANK 1 l D 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 1,11,111,N,and 1X 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. I DATE EXISTING UST DISCOVERED: 430b. I FACILITY'INVO!! ATION, FACILITY ID#(Agency Use Only) _ 0 0 0 3 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. 7-Eleven#32262 BUSINESS SITE ADDRESS 103. CITY 104. 2360 W. Grant Line Rd. Trac IL 'TANK DESCRIPTION TANK ID# P6157kq 5437 TANK MANUFACTURER 433• TANK CONFIGURATION:THIS TANK IS 434. 003 J Xerxes ® 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. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 6/2003 10,000 77 7 III. TANK USE AND=CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.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.OTHER(Specify): 439a. ...........................................................................................................................................................................................................................................................................................................................-.................................................................................. ....................... CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ® lb.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 [195.UNKNOWN 443. ...........................................................................................................................................................................................................-................................................................................................................................................................................... PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444a. ....................................................................................................................................................................................................................................................................................................................................................................................................................................................... ..................................-............... SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. .......................................................................................................................................................................................................................... ................................................... OVERFII L PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT V. PRODUCT[WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. ............................................................................................................................................................................................................................................................................. SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. ............. ........................................-.............-.............................................-................................................................................................................................................................................................................. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464x. ................................................................................................................................................................................................................................. ....................................................... SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. .......................................................................................................................................................................................................... ....................................................... P1PING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. "1+ "SENT,VAPOR RECOVERY(VR)AND RISEN/FILL PIPE PIPING CONSTRUCTION 464eVENT PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS [110.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 464e1. ........................................._..................................................................................-......................................................................................................................................................................................._..................................................................................................................................................................................... VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464E .............................................................................._.............................-................................................................................................................................................................................................................................................................................................................................................................................ ....4 ...._... VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 e ............ .....................................................................................................................................-................................-................................................................................................................................................................._.........._..._.........._............................... &.......... VR SECONDARY CONTAINMENT [11.STEEL ® 4.FIBERGLASS [110.RIGID PLASTIC [190.NONE [199.OTHER(Specify): 464h1. ..................................................-........................................................................................................................................................................................................................................................................................................................................................................................................................................................... ..... i a;:..... VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL [12.DOUBLE WALL ❑ 90.NONEa ................................................................................................................................................................................................................................................................................................................................................................................................... ...................................................................................................................................._.......... RISER PRIMARY CONTAINMENT N 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 446 j .............................................................-..............................................-..................................................................................................................................................................................................................................................................................................................................................................................... 464k. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC [390.NONE [199.OTHER(Specify): 464k1. ....................... FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451a-c. VII. HOER DISPENSER CONTAINMENT Q CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 0,r*-,_ 469a. ......................................................................._..........................................................................................................................._........................................................................................................................................................................................._......._...._.......................................................................................................................... �.......................... CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) •* 46w CONSTRUCTION 469c. VIII. CORROSION PROUMONr. STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION -- 448. It APPLICANT SIGNATURE' g CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided he in is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE � � � DATE 12,131 It, P Etl azo. APPLICANT NAME(print) Ian Moorhead 471' APPLICANT TITLE Env. Compliance Mgr. 472. UPCF UST-B Rev.(1212007)-1/2 www.unidocs.org