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Ah • • ; UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(Cine form per UST) • TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,Il,Ill,TV,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT [3 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE El 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4308 I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION q .� q FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DHA-Doing Business As) 3 Flying J Travel Plaza-#617 BUSINESS SITE ADDRESS 107 1 CITY 144 15237 N.Thornton Rd Lodi IL TANK DESCRIPTION TANK ID# 432 'TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ®1.A STAND-ALONE TANK 2.ONE IN A COMPARTMENTED UNIT. 3-Regular �� Complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 20000 1 III.TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMFRGFNCY GENERATOR FULL(HSC§252815(y) ❑ 6.OTHER GENERATOR FUEL 95.UNKNOWN ❑ 99.OTHER(Specif)= 439a CONTENTS PFTROLEUM: i ❑ Ic.MIDGRADE UNLEADED ❑ lb PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL. ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i ; 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify). 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 19 2.DOUBLE WALL 0 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL IN 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S iF : 444s SECONDARY CONTAINMENT 13 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER 7,JACKETED 445 • ❑ 90.NONE 95.UNKNOWN ❑99.OTHER Ci 445a OVERFILL PREVENTION I.AIJDIBI.E R VISUAL ALARMS 2.BALL FLOAT i 3.FILL TUBE SHUT-OFF VALVE 452• ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0 1.SINGLE-WALLED C9 2.DOUBLE-WALLED 0 99.OTTIER 460 SYSTEM TYPE ® 1.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 12636(a)(3)) 458 PRIMARY CONTAINMENT 0 I.STEEL -974 FtBERGt.ASS ❑ 8.FLEXIBLE 0 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specil'): 464a SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS 0 8.FLEXIBLE Ll 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTT FER(Specify), 464c PIPTNGrTURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WAIL ❑ 2.DOUBLE WALL ❑ 90.NONE. 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ ).STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) VAe 464al VENT SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) a VR PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10,RIGID PLASTIC 90,NOM 13 99,OTHER(Specify) 446 8 VR SECONDARY CONTAINMENT C3 1.STEEL 19 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 0 I SINGLI3 WALL E3 2.DOUBLE WALL 0 90,NONE 0A RISER PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS El 10,RIGID PLASTIC U 90,NONE U 99.OTHER(Specify) 464i 464`i RISER SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 0 99.01-HER(Specify) 4fAk 464k1 FILL.COMPONENTS INSTALLED 1.SPILL.BUCKET 0 3.STRIKER PLATE/BOTTOM PROTECTOR N 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMLNT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3,NO DISPENSFRS ❑ 90.NONE 469a CONSTRUCTION MATERIAL 1.ST1EL 19 4.FIBERGLASS 10.RIGID PLASTIC Q 99.OTHER if '' VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 448, IX. APPLICANT SIGNATURE CERTIFICATION-. I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and In full rAmollance with lepi requirements. APP AN DATE 470" March 15 2012 AP TC T NAME(print) 471 APPLICANT TITLE 472' Joey Cupp Environment Management UPCF UST-B-1/12 Rev.(12/2007)