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it M EVE ,,, <br /> UNIFIED PROGRAM CONSOLIDATED FORM ` <br /> UNDERGROUND STORAGE TANK p <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION N 1'V'f171O �NT <br /> E OF ACTION (Chxk one item only. For.9 UST pertnanmt clossaaaaas <br /> ure or removal,complete only this section and Sectiam I,I,III,IV,and ik d 430 <br /> NEW PERMIT 1'3'RENEWAL,PERMIT ❑ 5.CHANGE OF INFORMATION <br /> 6.TEMPORARY USTCLOSLRE Lj 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLO SED: i{J as DAEXISTING UST DISCOVERED: <br /> TE <br /> 4J06 <br /> 11'FACIliYTY INFORMA3'ION <br /> FACILITY TD ri(AgencyUse Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> K o -Nr®,v �r� /fit �/E4,) F/4 51 97 <br /> BUSINESS SITE ADDRESS ire N <br /> � SOJliI` C!{EZp � cDrGDO <br /> IL TANKDESCRIPTIO <br /> TANK IDN 432 TANK MANUFACTURER 433 TAM(CONFIGURATION: THIS TANK IS 434 <br /> /} ,V0 Z(jd ) 2.AST NOMPATANK <br /> aAIN <br /> ❑2.ONE NA A COMPARTMENTED UNIT. <br /> DATE UST SYSTEM INST ED 435 NU ree ra each cam in uie�mit <br /> /✓ TANK CAPAC YIN GALLONS 436 NUMBER OF S/YPA T NTS IN THE UNIT 437 <br /> IIL TANK USE A MCI,) TS; <br /> TANK USE ❑ la.MOTOR VE19CL.E FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑,./4'.HAZARDOUS WASTE(Imluda USeAOII) ❑ 5,EMERGENCY GENERATOR FUEL IHSC 125291.5(c)) <br /> ❑6.OTHER GENERATOR FUEL XrwS.UNKNOWN ❑ 99.OTHER S mify: 43% <br /> CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ It.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 <br /> 0 3.DIESEL ❑ 5.TET FUEL ❑ 6.AVIATION GAS <br /> ❑ 6.PETROLEUM BLEND FUEL .OTHER PETROLEUM (Specify): d7O4Z /L .s/£6/ 440a <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ I0.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM S eci : 440b <br /> IV,TANK CONSTRUCTION- <br /> TYPEOFTANK L UNGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ®.1,STEEL ❑ 3.P®ERGLASS ❑ 6.INTERNAL BLADDER 141 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99,OTHER 5 c' 444a <br /> SECONDARY CONTAINMENT 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 <br /> 90.NONE ❑ 93.UNKNOWN ❑99.OTHER S 445v <br /> OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE N/9 452. <br /> ❑ {._TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V: P.ROlIUCT( _41?IPING CONSTRUCTION. <br /> PIPING CONSTRUCTION ❑"I.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER pnJt 460 <br /> SYSTEM TYPE ❑ 1.PRESSURE 2.GRAVITY .CONVENTIONAL SUCPION ❑ 4.SAFE SUCTION[v CCR g2636(vx3) 45s <br /> PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 <br /> 90.NONE ❑ 95.[1NKNOWN (1 99,OTHER(Speelfy): 164a <br /> SECONDARY CONTAINMENT 1.STEEL, /.FIBERGLASS ❑ 8.FLEMBLE ❑ 10.RIGID PLASTIC 4Nb <br /> 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S-ify): 464c <br /> PIPMC?URBME CONTAINMENT SU TYPE ❑ L SINGLE WALL ❑ 2.DOUBLE WALL RL,90.NONE 461d <br /> VI'.VENT,VAPOR BEGONE ,, A)VD RI <br /> VENT PRIMARY CONTAINMEN 'R,1 FILL PIPE PTP;ING CONSTRUCTION <br /> T T.STEEL 4.FIBERGLASS U 10.RIGID PLASTIC 90.NONE LJ 99.OTHER(Spccify) 464° <br /> VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 4M.1 <br /> IO.RIGID PLASTIC O.NONE 99.OTHER(Specify) 4Wr <br /> VR PRIMARY CONTAINMENT U I.STEEL U 4.FIBERGLASS L1 10.RIGID PLA577C 0.NONE 99.OTHER(Specify) 464g <br /> V0.SECONDARY CONTAINMENT ❑ I.STEP! {. 4M I <br /> FBERGLASS 10.RIGm PLASTIC .NONE 99.OTRER(Specify) 464h <br /> VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL 4 Ihl <br /> 2.DOUBLE WALL NONE 4ML <br /> RISER PRIMARY CONTAINMENT 1.STEEL U 4.FIBERGLASS LI 10.RIGID PLASTIC .NONE 99.OTHER(Specify) 464j <br /> RISER SECONDARY CONTAINMENT I.STEEL /.FIBERGLASS I0.RIGID PLASTIC 0.NONE 99.OTHER S eci 4Mk <br /> P fy) <br /> FILL COMPONENTS INSTALLED 1 SPILL BUCKETle <br /> J.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP431 akc <br /> VII:_UNDER.DISPENSER:C.f11HTAINMENT(UDQ <br /> CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ J.NO DISPENSERS 90.NONE 469. <br /> CONSTRUCTION MATERIAL ❑ ).STEEL ❑ {.FIBERGLASS ❑ ...RIGID PLASTIC 99.OTHER S eci 469bc <br /> VIIICORROSION R(,),T CtYO <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) U 4.IMPRESSED CURRENT ❑ 6.ISOLATION „JE 448. <br /> IX. APPLICANTSIGNATURE <br /> CERTII7C5'TION, I certify that this UST System b compatible with the hazardous substance stored and that the Informatbo pravlded herein Is true,accurate, <br /> and io full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 470. <br /> APPLICANT NAME(print) 471' APPLICANT TITLE 472. <br /> i of E C <br /> UPCF UST-B-1/2 <br /> Rev.(12/2007) <br /> /L <br />