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Ada rd We , 6l FIED PROGRAM CONSOLIDATED F 6711 D q 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,11,117,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: 430x. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY TNkORMA TION FACILITY ID#(Agency Use Only) _ 0 0 0 t• 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#6 /LD5/5�©�_ 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434• 001 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 15,000 III. TANK t&ANI}-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 ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. ................................................. .......................................................................................................................................................................................................................................................................-.................................................................. ....................... CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ ]b.PREMIUM UNLEADED 440• ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. .............................................................................................................................................................................................................................................................................................................. NON-PETROLEUM:❑ 7.USED 01L ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 44 Ob. IV. T K!PONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.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. ............................................................................................................................................................................................................................................................................................................................................................ ................................................... 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 DUCT t WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ L SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. .......................................................................................................................................................................................................................................................................................................................-.................................. .. ................................................................................................................................................................ SYSTEM TYPE ® 1.PRESSURE [32.GRAVITY [13.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(a)(3)] 458. .................................................................................................................................................................................................................................................................................................. PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. . ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. .....................................................................................................................................�...................................................................................................................................................................... SECONDARY CONTAINMENT ❑ 1.STEEL r .FIBERGLASS ]!;L8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. .....LL............................................................................................................ PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WA ❑ 2.DOUBLE WALL ❑ 90.NONE 464d. VI. "ANT, VAPOR RECOVERY tvR>AND'IusER/TILLPIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ❑ 90.NONE [199.OTHER(Specify): 4464e. ... ................................-........................................................................................................................................................................................................................................................................-............................................................................................................................................. ........... .....464........ VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46641. .......................................................................__.........................-......................................................................................................................................................................................................................................................................................................................................................................................................... ....................... VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 466 g ............................................................................................................................................... .................................. ......................................................... ................................................................... .......... ..........-..................................................... 6.......... VR SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 446W ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .......I............. VENT PIPING TRANSITION SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4641. ....................................................................................................................................................................................-............................................................................................................................................................................................................................................... RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 446 . ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ �I.......... RISER SECONDARY CONTAINMENT [11.STEEL ® 4.FIBERGLASS [110.RIGID PLASTIC [390.NONE [199.OTHER(Specify): 4664k 1. .......................................................................................................................................................................... FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEIBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 4516-c. VII. UNDER DISPENSER CONTAINMENT( DC) ,, CONSTRUCTION TYPE ® 1 SINGLE WALL Q 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 901 48 ........................................................ ..._..... .................................... ......... .. ......... ............................................................... ... ... ... ..... .... M . .. 4696 CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) ;,' 4699ba VIII. CORROSION PROTICTIO STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. V SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided is true, accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATE7e_(,?,(D p, 470. APPLICANT NAME(print) Ian Moorhead 471. APPLICANT TITLE Env. Compliance Mgr. 472. UPCF UST-B Rev.(12t2007)-1/2 www.unidocs.org