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r.-11191g9 Tank UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK C OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per GST) V/107 `0 TYPE OF ACTION (Cluck on item only. Foran UST permanent closure or removal,complete only this section and Sections I.IL III,IV,and IX below) ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT © S.C'11ANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.LIST PERMANENT CLOSURE ON SITE R.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4e1 1 DATE FXISTINO GST DISCOVF:RFD: °bn 1. FACILITY INFORMATION FACILITY ID M Ugcmv Use Onhl BUSINESS NAME(Sana as FACILITY NAME or DBA-Doing Business As) Costco Gasoline(Loc.No.38) BUSINESS SII L ADDRESS I (IIY 1616 E.Hammer Lane Stockton IL TANK DESCRIPTION TANK 11)d ` 1u rANK MANUFACrI'RFR 1'1 TANK(T)NEIGIIRATION. THIS I:UK IS '' o I J » ❑ I.A 6TAND-AI ONI f:\NK 3 Containment Solutions ❑).ONL6A("f3\IPAR7 FlFNIEU I!?II L�v,;.l.l.•,.I.rae=li..,d,.,..r.n,�l,m m.I.. DATF UST SYSI EM INS TALLER TANK CAPACITY IN GALLONS NUMBER OF COMPAR'TMEN'TS IN 1111 LI I I' - March 2004 20,000 1 Ill.TANK USE AND CONTENTS TANK USE 17 it MOTOR VEHICLE FUELING ❑ Ib MARINA FL ELING ❑ IC.AVTAIIONFIIEI.ING J19 ❑ 3.C HI'VICAL PRODUCT STORAGE. ❑ 4.IL\ZARDOUS WASTE.UncIVJ<s usd Oib ❑ 5.EMERGENCY GENERATOR FUEL IHW5 2520n,'I ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99,OTHER (Spac'B'vn 4W., CONTENTS PR'INOII:C\I'. ❑ In RLOUL.AR t Nt LADED ❑ Ic MI)OKADELNLUADLD IN Ib.FREMIUMGNuvADED 4j6 ❑ 3.DIESEL ❑ 5.1147 FUEL ❑ 6.AVIATION GAS ❑ N.Ph:I ROI.Ft,.M BLEND FCFI. ❑ 9.OTHER PEI"ROIYUM IS cc41: 111t. NON-PFTROI F1 1,CISFU OIL, 1 PTPTIIANOI 11.OTHER NON-PETROLBM iS cifv: 491n IV. TANK CONSTRUCTION TYPE OF TANK 0 I.SINGI.F X%At I O 3.001140 F WAIT. ❑ ^S.1 \KN(1N'N IH I'RI\I:\R)'C'ONI'AINNIENI' ❑ I,STEEL N 3,FIBERGLASS 0 6.IN I I:RN{LBLADDEK 414 ❑ 7.STEEL,INTERNAL LINING ❑ 95.LN'KNOIV'N CI ".OTHER IS ofo): 444a SICO\DARYCONTAINMF:NT ❑ LSfF1%L 1113.FIRF:RGL\SS ❑ 6.11 XI Ii IUOR MEMBRANE LINER ❑ 7.3At'K1'1tD OS ❑ 90.NONE 0 95.UNKNOWN 99.OTHER 5 knlN OV FRFII.I.I1RFVFNTIfN1 ■ I.AUD113I F R VISUAL.AI..ARMS l-■7 2.BALI.FLOAT 11 i.FILL TURF SHUT-OFF VAI VF =" ❑ 4.TANK MEETS RE UIREMENTfS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0 1.SINGLE-WALLED a 2.DOLTILF.-W'.A LLF.D 99.OT IF.R 4^I' SYSTEMTYPE LPk[SSURE ❑ 2.GRAVITY ❑ 1CONVENTIONALSUC'TION 4.SAFESUCf10N 15l Ckv!6i aR3) I9n PRIMARY(ONTAINAI ENT 1.$TEFL a.FIRFN(it ASS N.FL EXIBI F I(1 RIGID Ill AN I Int 90.NONI ❑ 95.ON KNOWN ❑ 90.(11 HIR(S afVl: 464u SECONDARY CONTAINMENT ❑ I.STEEL Eff 4,FIBERGLASS O N.FEExiGLL ❑ 10.RIGID PLASTIC 4616 n5,UNKNOR'N ❑ 99.OTHERS uf)I: 4W, ❑ 9n,NONE ❑ P<- PIPINGTURBiNECONI\IS\IITI-SUMP I')TI: 0 (.SINGLE WALL 8 2.DOUBLE WALL 0 9(1 NONE Ila VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONS'T'RUCTION VENT PRIMARY coNfAINMEN I Ll 1.STEEL ■ II'MER(II AKS U In RIGID Ill A5Tv 09n.NONE 99 OfHERISt,who wac YJ.I VLSI SECONOAKYCONTAINNILNI 0 I.S'TEFL (9 4.1 atlEit I \NS ❑ 10 RHr)FL.1ti11C ❑ 'tI1,NONE '19.OITIER(SpecIfy) -H-ff I11 VR PRIMARY('ONTAINKIENT Ej 1.STFFI. I] 4.Ht3FRf 1 ARS ❑ 10 RIGID 'I ASTIC ❑ 9I1.NONE 0 9').OTHFR ISpcatfy) 1CAa IMeI VR SECONDARY CONTAINMENT 0 I.STEEL CC 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99.OTI IRR ISpeify I Is+n AWtI VENT PIPING TRANSITION SUMP TYPE I.SINGLE%V ALE 1 DOUBLE,WALL ■ 90.NONE ' R1SI:R PRIMARY CON'I'AI.NAIFN'r ■ I.S11.1'.1. 4.FIB1RGI ISS U 10.RIGID PLASI 11 Lj WL NONE U 09.0`111RIt(Spccify) 1641 4miI RISER SLCONDARY CONT\[NNILNT 1.STEEL U 44IBERGLAS$ El 10,RIGID PLASTIC JE 91).NONE Ll 99.OTHER(Specifyl 4b1. 4Ntl FILL CO`J PONF.NTS INSTALLED ■ 1.SPILL BUCKET ■ 3.STRIKER PLATE-BOTTOM PROTECTOR 90 a,CONT.AfNMFsFf SUMP 1f IJ^ VII.UNDER DISPENSER CONTAINMENT(UDC) C ONSI R1CHON 1)PIR O L SIN01 F.N'At I ❑ 1 DOURLF.WAI.1. ❑ i.NO OISPF NSFRS ❑ 'n1.NONF Yi9j CONSTRUCTIOk MATERIAL ❑ I.STEEL ❑ 4.FILUR(a.ASS M 10.RRAD PL ASTIC 0 99.OTIIERIS -cif,I 1^W` VIII. CORROSION PROTECTION SHF.ILCOMPONENf PROILCUON ❑ 1 SACMFICIAL ANODHS, ❑ 31MPRESSEUCURRENT 6.ISOI A IION IX. APPLICANT SIGNATURE CF.R-rIFICA TION: I cenify that this UST system N compatible uilh the li r rd0us substance stored and that the mformaltor provided herein is true,accurate, and to full cum liana milk Ir uiraments. APPLICANT SIGNATURE (� AT'PLR'_1NT NAMF(pnm) O` °1 APPLIC:1tNT TITLE David H Rogers Director of Real Estate Development U PCF I. - ll2 Rev.(12/2007)