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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check ane ken only. Fm an UST pm=mt closure or removal,complete only this section and Sections 1,11,111,IV,and D(below) 4M ❑ L NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43ae DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID 0(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Circle K Store 2701205 BUSINESS SITE ADDRESS im CITY IN 16470 Cambridge Lathmp IL TANK DESCRIPTION TANK ID 02 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 Xmcs ®1.A STAND-ALONE TANK ❑2.ONE M A COMPARTMENTED UNIT. "m' ,fw tech COMPMMM in 1be Lek. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 1/2/98 11,849 1 One III.TANK USE AND CONTENTS TANK USE IM 1a.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 0 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Uncut.Used Da) 0 5.EMERGENCY GENERATOR FUEL(HSC BH291.5(q) 0 6.OTHERGENERATOR FUEL 0 95.UNKNOWN ❑ 99.OTHER (Speei%): 439. CONTENT'S PETROLEUM: 0 Is.REGULAR UNLEADED 0 Ic.MIDGRADEUNLEADED ® Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL 0 5.JET FUEL 0 6.AVIATION GAS O 8,PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM ( 1 ): 440 NON-PETROLEUM:E3 7.USED OIL 10.ETHANOL 0 II.OTHER NON-PETROLEUM($ i ): 440u IV. TANK CONSTRUCTION TYPE OF TANKSIN ❑ I. GLE WALL 2.DOUBLE WALL 93.UNKNOWN 443 PRIMARY CONTAINMENT 0 I.STEEL 29 3,FIBERGLASS 0 6.INTERNAL BLADDER 444 01 STEEL+INTERNAL LINING 0 95.UNKNOWN ❑ 99.OTHER (Specify): 4440 SECONDARY CONTAINMENT 0 I.STEEL 3.FIBERGLASS 6.EXTERIORMEMBRANE LINER 0 7.JACKETED 445 90.NONE ❑ 95.UNKNOWN 99.OTHER(S eci% 445. OVERFILL PREVENTION 1.AU DIBLEAVISUALAIARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 04.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 111 DOUBLE-WALLED 99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVr1Y ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION R3 CCR f . 3 I 439 PRIMARY CONTAINMENT I.STEEL 99 4.FIBERGLASS B.FLEXIBLE 10.RIGID PLASTIC 46i 0 90.NONE ❑ 95.UNKNOWN 0 99.OTHE'R(S ): 464. SECONDARY CONTAUIMENT 1.STEEL 4.FIBERGLASS 8.FLEXIBLE 10.RIGID PLASTIC 4646 0 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S i ): 46k PPING/IURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 0 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRItARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.DINER(Specify) 46a, 464,1 VENT SECONDARY CONTAINMENT LSTEEL 0 4.FIBERGLASS 10.RIGID PLASTIC ® 90.NONE 99.OTHER(Specify) 4Nf 4Nn VR PRIMARY CONTAINMENT ❑ 1.STEEL /.FIBERGLASS ❑ 10.RICID PLASTIC 90.NONE 99.OTHER(Sped%) 464a 46 I VR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(SpeeL%) 4646 4NF1 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL N 90.NONE 4641 RISER PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS U 10.RIGID PLASTIC LJ 90.NONE ❑ 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT i641 ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 4m 46161 FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET ® 3.STRIKER PLATEIBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 431.< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE N 1.SINGLE WALL 0 2.DOUBLE WALL 0 3.NO DISPENSERS ❑ 90.NONE 4654 CONSTRUCTION MATERIAL I,STEEL 4.F®FRGLASS 10.RIGID PLASTic 0 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODE(S) 0 4.LMPRESSED CURRENT ® 6.ISOLATION Mt. DL APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the Information provided herein Is tnq accents and in full mm lianm with legal mulumenta. APPLICANT SIGNATURE - DATE 11/7/08 4'10 APPLICANT NAME(pnnt) RICK GOSSett 471' AllPLICANTTITLE Environmental Compliance Manager 472. UPCF UST-B-1/2 Rev.(12/2007) )