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BCE810199 Tankl UNIFIED PROGRAM CONSOLIDATED FORM e UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One fpm) per USTI TYPE OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections I, 11, 111, IV. and IX bellm 1 411 ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT W 5, C'I IANGE OF INFORMATION 6. TEMPORARY UST CLOSURE Q 7. UST PERMANENT CLOSURE ON SITE Q R. UST REMOVAL DATE UST PERMANENTLY CLOSED: "" I DATE. EXISTING LST DISCOVFRI:ID I" I. FACILITY INFORMATION FACILITY ID 0 (Agenp Uve Onli I _ FT I BUSINESS NAME (Same as FACILIT)' N:\\IE or DBA Doing Business As) - - Costco Gasoline (Loc. No. 38) BUSINESS SIT L ADDRESS " CITY 1616 E. Hammer Lane Stockton IL TANK DESCRIPTION TANK ID tt �( j, "' TANK MANUF\C"TL'HER "' 1 11:K (ONFIGURAI'ION: THISI ANK IS TA/� ❑• I. ASTAND-AI ONI TANK D 1 Containment Solutions ❑ 2 ONE INA COMPARTMEN I FU 1 \1I (nn1 61e .- r e !fin exfi non .1 1. DA 11: L'S "I' SYSTEM INSTALLED +'` TANK CAPA('ll'Y IN GALLONS 4111 NUMBIiR OP COMPARTh11 '� Il11 1'`.I - March 2004 20,000 1 Ill. TANK USE AND CONTENTS TANK USE 9 la MOTOR VEHICLE FUELING ❑ I h MARISA I-ILUNG ❑ Ic AVIA IION FUELING +)° ❑ 3. CIIEMICAL PRODUCT STORAGE. O 4.IIAZARDOUS WASTFim,1 a U.doia ❑ 5. EMERGENCY GENERATOR FUEL IHSC 1251914IC,1 ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ ".OTHER (S <ih)l 414' CONTENTS FETROLEUM', Q Is REGULARUNLEADED ❑ Ic. M11"ADEUNLEADEb ❑ 11, PREMIUM UNLEADED J10 ❑ 3. DIESEL ❑ S. JET FUEL ❑ 6. AVIATION GAS ❑ N. PETROLEUM BLEND FUEI- ❑ 9. OfHFR PETROLEUM 1S wI is 116e NON-PFTROITUM: Cj 7. USED 011, 0 I0. FTIIANOT. I I.OTIIER NON-PETROLEL:M S •cif l: J}b� IV. TANK CONSTRUCTION TYPE OF TANK ❑ L SI\GI F. W AT.[. IN 2, DOUBLE WALL O 95. UNKNOWN ni PRIMARY CONTAINMENT ❑ 1 sit I1 19 3. FIBERGLASS 6. INTERNALBLADDER +++ ❑ 7.S1I-.1.1. INTERNALLINING ❑ 95. UNKNOWN ❑ 99.OTHER (S,'�Ihl1 444, SECONDARY CONTAINMENT ❑ L SI l I E 3. FIBERGLASS ❑ 6. EXTERIOR VIP.MBRANF LINER ❑ ]. JA('KIIFD +4` ❑ 90. NONE E3 95. LINKNOW'N ❑ 99, OTHER (S nl ). 44`11 OVFRFILI. PREVENTION © L AUDIBLE & VISUAL ALARMS IN 2, BALL FLOAT Cj 3. FILL TURF SI IUT-OFF VAT\'F - - ❑ 4. TANK MEETS REQUIREMENTS FOR EXE MPTION FROM OVERFI LL PRE VENTION EQUI I'M ENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPINGCONSTRUCTION 0 LSINGLF.-WALLED _'.DOUBLE. -WALLED 099.OTIIER 41.11 SYSTEM TYPE LPRBSSVRE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAfESUCTION 33CC'Rk2616(+N3)1 41n PRIMARY CONTAINMENT L STEEL ❑ 4. FIBERGLASS TINJ N. FLF,XIBI.F ❑ 10 RIGID PLASTIC 41" ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(S ci(vl 46,1^ SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑• N. FLL'XIBLL ❑ 10. RIGID PLASTIC 41,11, ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(SI1 cuh1. 464, PIPIN6TI'R14INE CON I:AINNII N I' SI' ATI' I"1'I'l 0ISI\6IF%1Al1 19 .'DOUHll-\1:111 ❑'ro Nom 4Md VI. VEN"1, VAPOR RECOVERY (VR) AND RISER/ FILL PIPE PIPING CONS I RUC7IUN V EN'I PRIMARY (,ON TAINMENI" D , STEEL 94. FIBER(il ASS ❑ Ili RIGID PI. AS IIC' LJ 911 NONI011 OI"HER ISp,o 1)1 464c i l VENT" SECT)NDARY CONTAINMENT ❑ 1. STEEL 19 4. 1'IBERCil-ASS ❑ In RIGID PLASTIC' 0 I NONE. ❑ ^9 OTHER ISPscrttl awf 1411 VR PRIMARY CONTAINMENT ❑ I. STFFI 9 4. FIRFRGLASS lj 10 RIGID PI AS II(' ❑ 911. NONF ❑ 99. OTHFR,sr. e•1 11.19 1"dc1 \•R SECONDARY CONTAINMENT I. STELI. IN 4. FIBERGLASS 10, RIGID PLASTIC 90. NON[ 99.OTI IER 1 Spcalj 1 4'•4h io4hl VENT PIPING TRANSITION SUMP TYPE 0 LSI\UI.l. 11:\L1. _'. DOUBLE WALL• 90. NONE 464' RISER PRIMARY CONTAINMENT' w I. 6(L I Ll 4. 1 Jil RGI.ASS IC 10. RIGID PLAST9(1. NOM U 49. 01'HI.R ISpccify) 464) 4s,111 RISER SECONDARY CONTAINMENT 0 1511.11. LJ 4. II Hf RIA ASS U IO. RIGID PLASTIC • 9(1. NON[ E3 'A OTIRRISpecifyl 464k 414k1 FILL COMPONENTS INSTALLED IM 1 -SPILL ISLt KI.1' ■ 3. STRIKER PLATE.: BOTTOM PROTECTOR IN 4. C'ONTAFNMFNT sural' 41l-. VII. CINDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE I] I, SINGLE %%A] I EI 2. DOUBLF. WAI V ❑ 3. NO DISPENSERS ❑ 911 NONE 46%' C'ONSTRIC'TION MATERIAL ❑ I. STEEL ❑ 4. FIBERGLASS N 10. RIGIDPLASTIC ❑ 99.0TIIER(S cif) 4"°6'• VIII. CORROSION PROTECTION SITLLC-OMPONI'NI PRO'IE(-'I ION ❑ 2.SACRIFIC-IALANODLISI ❑ 1 IMPRESSED Ct.'' RREN1 (] 6ISOLATION IX. APPLICANT SIGNATURE CER] IFICA"I ION: 1 eertiR that this CS'1" scstem is Compatible with the haeard(us subslanee stored and that the information provided herein is true. accurate. and in full compliance "Rh I(a r uin•mrnu. APPLICANT SIGNATURE. DATE APPLR ANT \.\\II-: Iprint)° � APPLICANT ITLF. '}- David H R ers Director of Real Estate Development UPCF UST -B- 112 Rev. (1212007)