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L7 Ah 3CE410141 Tam 1 UNIFIED PROGRAM CONSOLIDATED FORM ? UNDERGROUND STORAGE TANK OPERATING PERAHT APPLICATION - TANK INFOR 3A'1'ION Ic�m (Inc eresil TYPE OF ACTION (Check one item only. Foran 1'ST pemsanent clnsw'e nr Ien,nval, complete only this Sema, and , s 1;11' I, IK. and IX helmsq omm+10 ❑ I. NEW I'ERb11T and I ❑ 3. RENEWAL PERMIT i. CTIA= INFORM. El G. TEMPORARY UST CLOSURE= 7. UST PERMANENT CLOSURE ON SITE 3, UST REMOVAL DATE USE PERMANENTLY CLOSEDDATE GYISTING I.SF DISCOVERED: 4av1• I. FACILITY INFORNIATION FACILITY ID ,4 C:Igrng' Use Onh1 r. -- - Il 51 BUSINESS NAME (Same as FACILI"CY NAME or DBA -Doing Business As) t Costco Gasoline (Loc. No. 38) UUSINGSS a]If ADURFSS 11^ CITY 1616 E. Hammer Lane Icy Stockton IL TANK DESCRIPTION TANK IT)4 j� 41: L C LANK MANUFA(TURER +'1 IAN K CONFIGHR:nION: THIS TANK IS an TA 0% I i 120,000 ContalnmantSolutions @11. A ST N0 -:619\'F TANK ❑2.ONE INA (O\IPAR'INIFNIHE, INI'J. UA"Cli US"1' =75.-MINSTALLED 435 March 2004 TANK C'APAC'ITY IN GALLONS +'( A•' lin umi:oa orin.rnl in 11.o unit. NUMBI:R OI' COMPARI'MIiN"I'S IN'I"HI' Uxl I' +?' 1 111. TANK USE AND CONTENTS 'I ANK LIST! TO la MOTOR VEHICLE FUELING ❑ IN MARINA FEELING ❑ I . AVIATION FLIELIN'O 41c ❑ 3.CHEMICALPRODUCTSTORAGE. ❑ 4.1IAZ.ARDOLIS WASTF.IIIUIYUte nwd Oil ❑ 5. EMERGENCY GENERATOR FUF,LIHSC' p2i29L1ni1 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOPN ❑ 99.OTHER ISpi,6w: 4w.. CONTENTS Piz]ROLEL'M: 111 la REGULAR UNLEAULD ❑ Ic. h111XHtADE UNLEADED ❑ Ib, PREhIIUAI CNLF:1UEp ua ❑ 3. DIESEL ❑ i. JET FUEL ❑ 6. AVIATION GAS ❑ Y. PETROLFUAI BLFND FUEL ❑ 9. OTHER PFTROLFUhI (S ccilo: NON-PFTROI.FUM: ❑ 7, USF U (.)II. ❑ III. FTIIANCII. II. OTT IER NON-PETROLEL:AI IS ifve abb 1V. TANK CONSTRUCTION TYT'F.OF TANK ❑ LSNGLF. II'ALI. O':. DOURLEWALL ❑ 95.(AkxO\v\ 1H PRIMARY CON 'rAINMEN'E ❑ I. STEEL U 3. FIBERGLASS ❑ G, INI'LKNAL HLAUUER yH ❑ 7. STEEL 1 INTERNAL LINING ❑ 95. UNKNOWN ❑ 99.OTHLR (SPacihl: 4u, SECONDARY CONTAINMEN T ❑ I. Sl vi 1. FIBERGLASS ❑ 6.EXTERI0R.NIFMHRAN'li I INkR ❑ 7.JACKETIA) 445 ❑ 90. NONF 95, WKNOWN ❑ 1/9. OTHFR f5 wcilN: u5a O\TRFfI L I'kFhT-NTION �i I, AL!I» I11.F. R V}SUAI. ALARMS O '- HALL FI OAT ?. FIL1. TUfiF SHl1T-OPE VALVE -_ ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FRONT OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION Ll I. SINGLE.-IVALLED IN3. DOUBLE -WALLED ❑99. OTHER 40 SYSTEMTYPE 0 LPRESSI!RE ❑ HIRAI` ❑ 3. C`,VENTION1LSt1CTION ❑ 4. SAPS SUCTIOK e3 CY'x,`rvaal.n(a ll 449 PRIMARY C ONITAINNIEN"f ❑ 1. STEF7- ❑ 4. FIRFR(,", X, FL FXIHLF 1] 10. MOTO III ASTIC out ❑ 9D. NONE 95. UNKNOWN ❑ 90. OfH1(RIS o:kT amt, S[COVDARY CONT:1INhIFNT t] L STEEL ❑ 4. FIBERGLASS (] e. FLGXIBLL ❑ IO. RIGID PLASTIC I61h ❑ 99. NONE ❑ 95. LINKNOWN ❑ 99.OTHER (Sp.9ilj i. 414, PIPING;IURBIN'ECONFA1NMENl' SUhIP'I'YI'E L5INGLE WALL 2, DGLIHLE R'A LL ❑911. NONE 4(4d VI. V _L_T, VAPOR RECOVERY (VR) AND RISER/ FILL PIPE PIPING CONSTRUCTION VEIN"1"PRISIARY C'UNL\INAiEN'I- ❑ L Sl'LHL I] 4 FIBERGLASS ❑ III RIGID I'LAS fIC 90. NONE I] 94. OI'HEH (Specdyl Inco not vbN'1'SECUNUAItT'('ONTAINh1EN'I' ❑ 1. STEEL (]■ a. PIHERGLASS O to RIGIU PEAS I'IC ❑ Ju NONE ❑ 99, 01' HER ISPaify) 4w( 46411 VR PRIMARY ('ONTAINMENT I. STE FI (] 4. FIHFRGI.ANN ❑ III. RIGID PLASTIC ❑ 911. NONE O ')9. OTHFR ISpceifyl Ede \'R SECONDARY ('ONTAfNN1LNT I. STEEL F LI 1 4, FIBERGLASS III. RIGID PLASTIC' 90. NONE 99.OTHER I Specify) 41,41: VENT PIPING TRANSITION SUMP TYPE L SISULIS W':1LL 1611:1 `. DOUBLE WALL 1 90, NONE 16-11 RISER PRIMARY CON I'.AIN611N f O L 6L.1 -.I. I] 4, 19BEkllLASS ❑ 19. RIGID PLASTIC ❑ 90. NONE (] 99.01-HEIZ ISpccify) 4641 46411 RISER SECONDARY CONTAINMENT 0 LSTELL E3 4, FIBERGLASS El IO. RIGID PLASTIC IN 'XI. NONE 0 99.OTIIRR 4SpeclRl 4111k 1016'1 FILL COMPONENTS INSTALLED 1 I. SPILL BUCKET ■ ?. STItIICF'R PL1TF.'BOTTOM PI20TFCTDI2 ■ 4.CONL\INMF.Nr SUh1P a51,., Vii. TINDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE I] L SINGLE WALL 0 '-. DOIiRLE WAI L ❑ 3. NO OISPFNSFRS ❑ 90. NONE 4e9= CONSTRUCTION MATERIAL ❑ 1. STHPL ❑ 4. PIBLRC.LASS O 10. RIGID PLASTIC ❑ 99.0THER(Swok) 4641.., VIII. CORROSION PROTECTION S I EEL C'OMPONFN I" PROI'EC'TION ❑ 2. SACRIFICIAL ANODEIS) ❑ 4 1MPRESSEUC'C'RIMN'ICC 6, ISOLATION ==+ IX. APPLICANT SIGNATURE CERTIFICATION: I ecitify that this CST slslem is c6mpalible with the hazarcinus substance stnred end (hal the infnrmatian provided herein is true, accurate, and in Fall coul Iiance,+ilb Iv La c(uirrosnts. SDI T[•eN7a R� TCM-e®moi, y <:a APPLICANT NAME (pliln) 'O1 APPLICANT TITLE '- David H Ro ers Director of Real Estate Develo menl -1 UPCF UST -H- I/2 Rev.(1212097)