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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form Der UST) TYP OF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections 1, 11, III, IV, and IX below) 430 I. 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: 4301 I DATE EXISTING UST DISCOVERED- 430b L 'FACILITY RCMRMATION'::: FACILITY ID # (Agency Use Only) _ _ q L 1 BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 BUSINESS SU ADDRESS 103 C lot - IL TAW DFSCREMON... c, TANK [D 432 �� TANK MANUFACTURER 433 TANK CONFxTIItATION: THS TANK IS 434 ❑ L ND -A r ATMENTED / l `' Z AdJ �. 1� �C ONE t AR UNIT. /� " ` �. L rSvY �, ae one for each m the =t. DATE UST SYSTEM INSTALLED 435 TANK CAPACrfY IN GALLONS 436 NUMBER OF COMPARTMENTS IN TIT UNIT 437 Z�c 220 IIG`TANK=USE:AND CONTI:IVTS TANK USE ❑ ta. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ le. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (lododa Used cm) ❑ 5.4hffRGENCY GENERATOR FUEL [HSC 125281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ ic. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS 8_RETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM $ 440a NON -PETROLEUM: PrT7,USED OI, ❑ 10. ETHANOL t 1.OTHER NON PETROLEUM f,%L, 440b ;.TANK CONSTRUCTION . TYPE OF TANK ❑ I. SINGLE WALL DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.,STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 STEEL+ INTERNAL LINING [195. UNKNOWN ❑ 99. OTHER (S 444a SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 3. FBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN99.OTHER (S ): _ ' ' cy L r r 445a OVERFILL PREVENTION 1. UDtBI E VISUAL ALARMS 2 BALL FLOAT ❑ 3. FILL TUBE SHUT-OFF VALVE 452 Ia1,4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V.`PRODUCT l WASTE PIMG CONSTRUCTION PIPING CONSTRUCTION S LE -WALLED ❑ 2. DOUBLE -WALLED ❑ 99. OTHER 460 SYSTEM TYPE a,I. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION ('-3 CCR 12636(.x3)] 458 PRIMARY CONTAINMENT [i� I. STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 4641 SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN99.OTNER(Sp-*): . _ / 464e PIPINGrrURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL 2. DOUBLE WALL 90. NONE 464d . VL VENT,VAPOR . COVERY (VR) -AND RUSE R / Fu Pa PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT . STEEL 0 4. FIBERGLASS 10. RIGID PLASTIC 0 90. NONE E3 99. OTHER (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 0 L STEEL 4. FIBERGLASS 11 10. RIGIDPLASTIC 90. NONE 99.OTHER (Specify) 464f 464f1 VR PRIMARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE 0 99. OTHER (Specify) 4648 464 i VR SECONDARY CONTAINMENT L STEEL 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h 464hI VENT PIPING TRANSITION SUMP TYPE Q 1. SINGLE WALL El 2. DOUBLE WALL 0 90. NONE 464 RISER PRIMARY CONTAINMENT 0 L STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC 0 90. NONE 0 99. OTHER (Specify) 464j 46fI464k RISER SECONDARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS13 10. RIGID PLASTIC CJ 90. NONE ❑ 99. OTHER (Specify) 464k1 FILL COMPONENTS INSTALLED 13 1. SPILL BUCKET 13 3. STRIKER PLATElB07TOM PROTECTOR 4. CONTAINMENT SUMP 451" VII. UNDEWDW%NSER CONTAP4M&r.(U1W- ). '. CONSTRUCTION TYPE ❑ 1. SINGLE WALL p 2. DOUBLE WALL ❑ 3. NO DISPENSERS . NONE 469a CONSTRUCTION MATERIAL 1. STEEL 0 4. FIBERGLASS lo. RIGID PLASTIC Ij 99.3THER ( ) 469bt VIII.' CORROSIUN PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. RAPRESSED CURRENT 6. ISOLATION 441 EL APPLICANTSIGNATURE 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 compliance with legal requirements. APPLICANT SIGNATURE DATE 470. q APPLICANT NAME (print) 1 an APPWANT TTILE 471_ \ CV- ] }�-- f0 - UPCF UST -B- 1/2 Rev. (12/2007) V"