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U tFIED PROGRAM CONSOLIDATED FORW <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form Per UST) <br /> TYPE OF ACTION (Check one ikm4 only. For a UST closure or removal,compleh•only this section and Sec/ions I,II,IPI,IV,and LY low) <br /> 430. <br /> ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 43%DATE UST PERMANENTLY CLOSED: 430x. DATEEXISTINGUSTDISCOVERED: <br /> L FACILITY INFORMATION <br /> 1. <br /> FACILITY 11N(Agency Use Only) - <br /> 3. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> M Mini Mart 104. <br /> BUSINESS SITE ADDRESS 103' CITY <br /> 1756 Wilson Way - Stockton <br /> IL TANK DESCRIPTION <br /> TANK ID 0 'A 1 po 432' TpN]{MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434. <br /> f r Prepared Modem Building ❑ 1.A STAND-ALONE TANK Ccam�.en=wse fm n <br /> compiny ® 2.ONE IN A COMPARTMENTED UNIT compateam is the ana <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITY INGA�I L"Sot S 436. NUMBER OF COMPARTMENTS IN THE UNIT 431. <br /> -1998 7. 1`{-Q g 1k OQb t 2 <br /> III. TANK USE AND CONTENTS <br /> TANK USE ® 1a.MOTOR VEHICLE FUELING ❑ 1b.MARINA F11EL G Cl 1a AVIATION FUE1,11,10 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used Oa) ❑ 5.EMERGENCY GENERATOR FUEL[HSC 925281.5(4)]] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): <br /> CONTENTS PETROLEUM: ® ]a REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440' <br /> ❑ 3.DIESEL ❑ 5.SET FUEL ❑ 6.AVIATION GAS 440a <br /> ❑ 8.PETROLEUM BLEND FUEL_❑ 9.OTHER PETROLEUM(Specify): <br /> NON-PETROLEUM: 7.USED OIL ❑ 10.ETHANOL aaub <br /> ❑ FL OTHER NON-PETROLEUM(S ify): <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK El LSINGLEWALL 02.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRIMARY CONTAINMENT N 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 644' <br /> [1 7.STEEL, INTERNAL LINING ❑ 95.UNKNOWN [3 99.OTHER(SPecifY): -444& <br /> SECONDARY CONTAINMENT ® 1.STEEL ®3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER ❑ 7.IACKETED 4a5. <br /> ❑ 90.NONE _❑ 95.UNKNOWN ❑99.OTHER(Specify): 445e. <br /> OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ® 2.BLL AFLOAT [13.FILL TUBE SHUT-OFF VALVE 45x. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT <br /> V.. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION_ ❑ 1.SINGLE WALL_0 2.DOUBLE WALL ❑ 99.OTHER _ _ -._460_ <br /> SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 9263E XM 458. <br /> pRIIvIARY CONTAINMEPIT ❑ L STEEL ® 4.FIBERGLASS ❑ 6.FLEXIBLE ❑ 10.RIGID PLASTIC 464. <br /> ❑ 90.NONE [195.UNKNOWN El99.OTHER(Specify): 464.. <br /> SECONDARY CONTAINMENT ❑ I.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b. <br /> _❑ 90.NONE __ 95.UNKNOWN [199.OTHER(Specify): <br /> PIPINGnURBIIVE CONTAINM_ ENT SUMP TYPE _❑❑ 1.SINGLE WWALL ❑ALL ❑ 2.DOUBLE 90.NONE 4644. <br /> VI. VENTS VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): q ); <br /> __ _ ---'-'-- bff <br /> VBNl'SECONDARYCON'1'A1NMh'Nr U LSTEEL LI 4.FIBERGLASS U 10.R1GIDPLAS'rIC U 90.NONE U 99.0't'HER(Speciy 464fl. <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): <br /> 1. <br /> VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46 p1; <br /> VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464. <br /> RISER PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑99.OTHER(Specify). 44& <br /> t_ <br /> RISER SECONDARY CONTATtVT4ENT ❑ 1.STEEL [34.FIBERGLASS ❑ 10.RIGID PLASTIC El 90,NONE El99.OTHER(Specify): 4601. <br /> FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEiB 6 PROTECTOR ❑ 4.CONTAINMENT SUMP 451aK. <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) <br /> CONSTRUCTION TYPF. ®_I.SINGLEWALL ❑ 2.DOIIRLF.WAL1.__❑ 3.NO DISPENSERS El 90,NONE 469+. <br /> CONSTRUCTION MATERIAL ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) q <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION [12.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION - 448. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substame stored and that the informationa fed herein is true, <br /> accurate in fun com non ith le a1 re ui <br /> SIGNATURE rementa <br /> APPLICANT .{--� DATE 7/$/2009 470. <br /> UPCF UST-B Rev.(12/2007)-1/3 www.4midoes.org <br />