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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, II, 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: 430a DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) 3 8 7 0 1 4 - 1 BUSINESS NAME (Same as FACILITY NAME or DBA-Doing Business As) 3 7-Eleven, #41531 BUSINESS SITE ADDRESS 103 CITY 104 3379 N Tracy Blvd . Tracy IL TANK DESCRIPTION TANK ID # 633 -598 -04 432 TANK MANUFACTURER 433 TANK CONFIGURATION : THIS TANK IS 434 Xerxes ❑ 1 . A STAND-ALONE TANK ® 2 . ONE IN A COMPARTMENTED UNIT . Complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 10/2021 121000 2 III. TANK USE AND CONTENTS TANK USE N la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281 .5(c)1 ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 N 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440a NON-PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11 . OTHER NON-PETROLEUM (Specify): 440b IV, TANK CONSTRUCTION TYPE OF TANK ❑ 1 . SINGLE WALL N 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1 . STEEL N 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1 . STEEL N 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 N 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 N 2. DOUBLE-WALLED ❑ 99. OTHER 460 SYSTEM TYPE N 1 . PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 123 CCR §2636(a)(3)1 458 PRIMARY CONTAINMENT ❑ 1 . STEEL N 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I . STEEL N 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE ❑ I . SINGLE WALL N 2, DOUBLE WALL ❑ 90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1 . STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1 . STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f 464£1 VR PRIMARY CONTAINMENT ❑ 1 . STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464g 464al VR SECONDARY CONTAINMENT ❑ 1 . STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h 4641il 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) 464j 464' 1 RISER SECONDARY CONTAINMENT ❑ 1 . STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1 . SPILL BUCKET N 3. STRIKER PLATE/BOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 45la-c VII. UNDER DISPENSER CONTAINMENT; (UDC) CONSTRUCTION TYPE ❑ 1 . SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1 . STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT N 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 SIGNATURE DATE azo. APPLICANT NAME (print) 471 . APPLICANT TITLE 472. Crystal Justice Construction Manager UPCF UST-B - 1/2 Rev. (12/2007)