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r6 ;3CE810199 Tank3 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one fornit per USTI it r) TYPE OF TACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections 1, 11, III, IV, and IN below) Itu I. NEW PERMIT ❑ 3. RENEWAL PERMIT i] < CIIANGE OF INFORMATION 6. TEMPORARY UST (CLOSURE El 7. UST PERMANENT CLOSURE ON SITE P s. UST REMOVAL DATE UST PERMANENTLY CLOSED: I)0i I DATE EXISTING US T U scovFRED: 1io6 1. FACILITY INFORMATION FACILITY [DH (Ag,mv Use Onh) _ _ BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) ' Costco Gasoline (Loc. No. 38) BUSINESS SI I L ADDRESS 1i' CITY Ifa 1616 E. Hammer Lane Stockton IL TANK DESCRIPTION TANK ID ",y �1 �- `y, �'= A J �� 5, �� TANKMANUFACiI'RF.Lt I'I '1"AN'K CONFIGI IRA' TON: THIS TASK IS III 1 - �' Q L A STAND-ALONE TANK 3 Containment Solutions 02. ONF IN A CO\IPARTAIFN'I'IID UNIT Co'er1.1. ,ne nose for eu4 nnnpannirnl in 16v unit NUMBER UP CUMPAR'I'MENI'S IN'I'HI'. UN'I'T'--- °i? DA 11: U3lSYS-EEM INSTALLED +;5 'TANK C'APAC'ITY IN GALLONS +'-, March 2004 20,000 1 Ill. TANK USE AND CONTENTS IANKUSL Q to NIMORVEHICLEFUELINU ❑ IT, MARINA FUELING ❑ IC.AVIATIONFUELING 419 0 3.CHEMICALPRODUCr STORAGE 0 4. I IAZARDOUS WASTE. Ondudcs Ubrd Oil ❑ 5.FhtFRGFNCYGF.NER:ATORFUF.L[Hsale52sI5a11 0 b. OTHER GENERATOR FUEL Q 95. UNKNOWN ❑ 99.OTHER (Specify): 451a CONTENTS PEIROLEU!M: ❑ In. REGULAR UNLEADED 0 Ir. full LRIRADELINLEADED Q Ib, PREMIUM UNLEADED I11) Q 3. DIESEL 0 5. JIT FUEL ❑ b. AVIATION GAS ❑ S. PETROL FUM BI.FND FUEL ❑ 9, OTHFR PEI RUT FUM I5 gcIINr 4'I0. NON-PFTROIEUM: ❑ 7. USED 011, 0 111. ETITANOI. II.OTIIERNON-PETROLEL]I(S Nci1V1: A+"h IV. TANK CONSTRUCTION TYPEOFTANK U I.SINGLRt\'ALI. CE '.DOURI.FW'AI.I. 0 45. USIKNOWN IH PRINIARYCONEAINNIEN'E ❑ LSIEEL IN 3. FIBERGLASS 0 6ANTERNALDLADDER I++ ❑ 7. STEEL , INTERNAL LINING 0 95. UNKNOWN Q 49.0THER ISpccifpP H{+ SP.COND4RY CONTAINNIP:NI' 0 L STEEL @13. FIBERGLASS 0 6. FXITIRIUR. MEMBRANE LINER U 7. IAC'K TFT) II9 C] 90. NONE 09. UNKNOWN ❑ 99. OTHER (S wrIPoY. 445;, OVERFILI. PREVENTION (71.AUDIHI.ERA93UALALARUS O2.RAI.I. FLOAT ❑ 3. FII.]. TU14F SI ItIT-OFF V.AT.VF. ->- ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONSTRCCrION ❑1. SINGLE -WALLED IN 2 -DOUBLE -\PALLED 099. OTHER Jrn Sys TENT TYPE 11 1. PRESSURE ❑ 2. GRAVITY 0 3. CONVENTIONAL SUCTION 0 4. SAFE Silt'i lON p3 CCR t_n;6cnl)II +56 I'll INIARY COSTA INNIFNT ❑ 1. STEEL ❑ 4. FIBFROASS 7 S. FLRXIBIF ❑ IQ RIGID I'1 AS IR 11" ❑ 90. NONE ❑ 95. UNKNOWN 0 99.0114RR(S -cify): 464a SLC'ONDARY CON'rAINNILNT ❑ I. STEEL ❑ 4. FIBERGLASS 17 N. FLEXIBLE 0 10. RIGID PLASTIC 4611, 0 911. NONE ❑ 95. LIN KNOWN 0 99. OTHER 1 Spucnyl: 4S4' PIPINGTUKRINE CON I'AINNIEN T SUMP 1)'I'E El ESWL;LE WALL N2. DOUBLE WALL 090.\'ONE +1.+d Vl. VENT, VAPOR RECOVERY (VR) AND RISER FILL PIPE PIPING CONSTRUCTION VENT' PRIMARY CON I'AIN IEN'1" ❑ 1SI'FEL ❑• 4.FI8ERGLAS5 L3 In KfUlD PLAS I'IC ❑ 40. NONE ❑ 99,01"11FRISpmfy) 464c _na0 VEN'I'SELONDARY('ON'IANNILNE ❑ LSIEEL (E J -FIBERGLASS ❑ IQ RIUMPLASIIC ❑ 40. NONE ❑ V9. OTHCRtSpcc11'y) leaf Jhlll VR PRIMARY( ONTAINNIFINt' U 1, STFFI. 7 4, FIRF.RGIASS 0 10 RIGID PLASTIC 0 ')O. NONE 0 911. OTHER ISpecltg) 10, 1600 VR SECONDARYCONTAINM ENT I. STEEL CE 4. FIBERGLASS 0 10. RIGIDPLA-STIC CI 9n. NONE 0 91). OTHER (Specify) +WM1 Intl VENT PIPING TRANSITION SUMP TYPE El 1. SINGLE WALL 0 2 DOUBLE WALL CE 90. NONE +64' RISER PRIMARY CON 'rAI.NNIEN'r 7 I. STE R]. 0 4.1 IRERGLASS U IO RIG(D PLASTIC U 99.140NE U 020111 Ot ISpcci fy) 44, 461 ,1 RISER SLCONDARYCONLAINNi ENT 0 I. STEEL Ll 4.17IBERGLASS 0 12 RIGID PLASTIC @9 90. NONE U 99. OTHER tSpccif) 1 Mllk TWO FILL COMPONENTS INSTALLED 91 LSPILLBUCKEF LI3. STRIKER PLATI9BOTTOM1I PROTF.CTOIi LIU 4CONTAINNIENTSUNIP 411- V11. UNDER DISPENSER CONTAINMENT (UDC) CCONSTRII('TION T1'Pll 17 1. SING(F, WAI.I. ❑ 2 Dour LE: WALL ❑ '. NO ULITNSFRS 0 ')0, NONE 419- CONSTRUCTIONMATf RIAL ❑ I. STEEL U 4.111s[k6L.ASS 17 10. RIGID PLASTIC ❑ "'�. 6TIIfiR lSncc-ifyl +'',I"' Vlll. CORROSION PROTECTION SI ILL COMPONENT PIWIECIION ❑ 2.SACRfFI0:AI. %\0DbIS1 ❑ I ITESSEDC'URKENT I] 6. ISOLA IION --' IX. APPLICANT SIGNATURE CER'I'I FI CATION: 1 certify 111 At Ibis 1: ST system is wlnpaHit le n'ith the hazardous snhstanee More It and Ihnt the informative) pi PN ided herein is True, accurate, and in full cmv Ranee ailh Il''a f lirvoicnts- 1,I,CA+N'I SIGNAIURI, DAM % /Z__ Ivo +'1 APPLICANT NAXIF(pollt) API'EA%NN T T11 [T +'- David H Rogers Director of Real Estate Development U PC F UST -11- 112 Rev. (1212097)