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D PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK 6I� OPERATING PERMIT APPLICATION-TANK INFORMATION (O a form per s TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections/,/I,III,IV,,and IXbelow) ❑' 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: a3o. DATE EXISTING UST DISCOVERED: 4306. I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - c I. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As 3. Safeway Fuel Station 2707-10 BUSINESS SITE ADDRESS 103. 1 CITY IN. 6425 Pacific Ave Stockton IL TANKDESCRIPTION TANK ID# '� 0515706632 TANK MANUFACTURER 433- TANKCONFIGURATION:THIS TANK IS 434. B Modem Welding ❑ 1.ASTAND-ALONE TANK Compl4le one page for each ® 2.ONE INA COMPARTMENTED UNIT con4geenens m aK omc DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 4/2004 10,000 2 M. TANK USE AND CONTENTS TANK USE N la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ la AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Include:Used OO) ❑ 5.EMERGENCY GENERATOR FUEL(HSC I25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439% CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MDGRADE UNLEADED N 1b.PREMIUM UNLEADED 4°0. ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.0111ERPETROLEUM(Specify): 44oa NON-PETROLEUM:❑ 7.USED OIL 0 lo.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440h IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443, PRIMARY CONTAINMENT N 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 644. ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 444. SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 415. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445. OVERFILL PREVENTION ® L AUDIBLE&VISUAL ALARMS N 2.BALL PLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTIONE UIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 99.OTHER 4% SYSTEM TYPE N 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION(23 CCR§2636(a)(31) 458. PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS N S.FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTBER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS N 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464h ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPING/TURBINE CONTAINMENT SUMP TYPE N 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4464 VENT SECONDARY CONTAINMENT [11.STEEL N 4.FIBERGLASS [110.RIGID PLASTIC 1190.NONE ❑ 99.OTHER(Specify): 40. VR PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 4664& VR SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): qW! VENT PIPING TRANSITION SUMP TYPE N L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE d64i' RISER PRIMARY CONTAINMENT N 1.STEEL4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify): 46 [1El134it. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): g4kk FILL COMPONENTS INSTALLED N 1.SPILL BUCKET N 3.STRIIUM PLATEIBOTTOM PROTECTOR . N 4.CONTAINMENT SUMP 451. VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469x. CONSTRUCTION MATERIAL ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 469b. 469'. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENTfi.ISOLATION ue. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information"rov(ded herein is true, accurate,And in full cum fiance with le al re uirements. APPLICANT SIGNATURE DATE June 4,2009 470. APPLICANT NAME(print) Butch Hobson 471' I APPLICANT TITLE Safety and Env. Affaifs Mgr 4n.