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UNIFIED PROGRAM CONSOLIDATED FORM LOA UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(oae rertn usT) TYPE OF ACr10N (Check one item only. For an UST pmtllenmt closure or Oemoval,COff plde only this cation aM Sxdom 1,11,BI,IV,and IX below) 4" ❑ 1.NEW PERMIT 0 3.RENEWAL PERMIT ® 3.CHANGE OF INFORMATION b.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE B.UST REMOVAL DATE[1ST PERMANENTLY CLOSED: 4"b I DATE EXISTING UST DISCOVERED: 459E CILITY IDM(AI. FACILITY INFORMATION FAperRry Use Gdyj - - 1 BUSINESS NAME(Same u FACILITY NAME or DBA-Doing Busuras AS) 3 St Josephs Medical Center BUSINESS SHh ADDRESS 18W North California street Im CITY Stockton I IL TANK DESCRIPTION TANK ID o 43Z TANK MANUFACTURER 4D TANK CONFR MRAT .THI TANK I 4M 360002310360103603 Owens Coming (M LA STAND-ALONE TANK ❑LONE M A COMPARTMEMF.13IMrt. DATE UST SYSTEM INSTALLED 43501e 6w"s' in tM1e WeL TANK CAPACITY IN GALLONS 436 NUMBER 1992 20,000 OF COMPARTMENTS IN THE UNIT 457 1 UL TANK USE AND CONTENTS TANK USE 0 IL MOTOR VEHICLE F U E LBJ" 0 Ib.MARINA FUELING 0 I..AVIATION FUELING 4" 03.CHEMICAL PRODUCT STORAGE 04.HAZARDOUS WASTE IIotlWwlAot 010 ® 5.EMERGENCY GENERATOR FUEL I118C I2sz315(411 0 6.OTHER GENERATOR FUEL Q 95.UNKNOWN El ".OTHER( ). 4H. CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED 0 la MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED 4a ® 3.DffSEL 0 S.IEf FUEL 06.AVIATIONGAS 08.PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM 4ep, NON-PETROLEUM: ].USED OIL 0 10.ETHANOL 0 11.OTHER NON-PETROLEUMS y� IV. TANK.CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL 9s.UNKNOWN 5(J PRIMARVMNTAINMENr ❑ 1.STEEL Q3 3.FIBERGLASS 0 6.INTERNAL BLADDER ❑ ].STEEL+MTERNAI,LTLMG 095.UNKNOWN 99.03HER SECONDARY CONTAINMENT ❑ I.STEEL 3.F®ERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ ].2gCKERD 445 ❑ 90.NONE 95.UNKNOWN ❑99.OTHER(S ): My OVERFBY PREVENTION 1.AUDIBLE @VISUAL ALMMS Z.BALL fLOAT 3.FILL TUBE SHUT-OFF VALVE1411 0 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFU.PRFVFNTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED 99.OTHER SYSTEM TYPE 0 1.PRESSURE 2.GRAVrry 3.CONVENTIONAL SUCTION 4.SAEESUCTION x3cvR 2 LSTEEL 4.FIBERGLASS 8.FLEXIBLE 10.RIG'PLASTIC0 90.NONE 0 95.UNKNOWN 13 OTHLR(SP ify)Y CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 8FLEXIBLE 10.RIGlDPLASTIC0 90.NONE ❑ 95.RINKNOwN99.OTHER(S 'y):PIPING/IURBINE CONTAINMENTSUMPTVPE 1.SINGLE WALL 2.DOUBLEWALL VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL,PIPE PIPING CONSTRUCTION VENT PRIMARY CONTALNMEM 1.$TEEL 4.FIBERGLASS L1 IOAUGIDPLASTIC 0 90.NONE Ll 99.0THER(Spee*) 465. MMI VEIN SECONDARY CONTAINMENT EJ 1.STEEL LI 4.FIBERGLASS 10.RIGin PLASTIC 90.NONE 99.OTHER(Spec:y) Mfr Wit PRIMARY CONTAINMENT 4.FIRFRGLASS 10.RIGD)PLASTIC 90.NONE 99.OTIIER(SPwify) 461E VR SECONDARY CONTAINMENT E3TSTFEL 0 4,FIBERGLASS 10.RIGID PLASTIC 90.N0NE 99.O K(Swiy) 46tl 6 61 VEIN PIPING TRANSITION SUMP ME 0 I.SB4GLE WALL 2.DOUBLE WALL 90.NONE 461. RISERPRIMARY CONTAINMENT' I.STEEL 4.FIBERGLASS IO.RIGID PIA51'IC' W.NONE W.OTHER(Spedy) Maj MSERSECONDARYCOMAI[AIEM I.STEEL 4.FIBERGLASS IU.RIUMPLASTIC CO 90.NONE U W.OTHER(Spedfy) Mot A FILLCOMPONENTS ttiSTALLED 1.SPAY BUCKET FJB }.STRIKER PLATOTTOM PROTECTOR 4.COMAINMM ESUMP 451- `c VQ.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE U I.SINGLE WALL 0 2.DOUBLE WALL ❑J.NO DISPENSERS III9p.NONE M94 CONSTRUCTION MATERIAL I.STEFI, 4.FIBERULASS 0 10.RIGID PLASTIC 99.OTHER(S ) M96c. VUL CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODE(S) 0 4.IMPRESSED CURRENT ®b.ISOLATION 418. IX. APPLICANT SIGNATURE CERTIFICATION: 1 eera(y Wt thH UYIsya Y compatible with the Yaardous subtame stored amid that the Imifotmtbmi provided Tmreiu u rrx,escarate, and iu I. rmim • e with nwmih. APPLICANT SIGNATURE �' GATE October 7,2008 45(' APPLICANT NAME(prier) John c.Sts u71 NT T APPLICAITLE- On, 9B Assistant Chief Engineer UPCF UST-B-1f2 Rf fed R Iu9