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�k <br /> . ....... .. ........... ------ <br /> M <br /> ................. <br /> C 1..„x <br /> UNIFIED PROGRAM CONSOLIDATED FORM 236, <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERNUT APPLICATION-TANK INFORMATION(one to='"UST) <br /> d 430 <br /> or=Oval,complete only this wbou sort sections 1,11,III,IV,and IX below) <br /> TYPE OF ACTION (Check one item only. For an an 'am E] 5.CHANGE OF INFORMA N� - <br /> US= 'PO, <br /> F1 1.NEW PERMIT Z 3 V7TPNNR0T 00 <br /> [1 6.TEMP n 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL 43 <br /> DATE UST PERMANENTLY CLOSED: ---a DATE EXISTING UST DISCOVERED, <br /> I. FACILITY INFORMATION <br /> f'4' ;Z5 <br /> -a f-� LJS <br /> IV,and below) <br /> FACILITY ID#(Agency Use Only) <br /> LITY <br /> P(S <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 4 5 <br /> to <br /> BUSINESS ADDRESS Ion CITY <br /> ed, _6 <br /> IL TANK DESCRIPTION N TANK IS <br /> 47 <br /> TS TEDU <br /> To <br /> TA Er <br /> r <br /> CO <br /> T 432 TANK 19 <br /> TANK 11) MANUFACTURER 433 rTCONFIGURATION: THIS <br /> I..A CONFIGURATION: <br /> TANK <br /> 0 111 <br /> Ff]2.ONE IN A COMPARTMENTED UNIT- <br /> indL,uMit <br /> f.'= VM� ��431� <br /> .X, �ZTMW�� <br /> TANK CAP Co10�MBEROFLOMP <br /> 4-35 TQW;�IN GALLONS 436 SIN,71 - 431� <br /> DAM UST SYSTEM INSTALLED 35'0 - z <br /> '04 4-'1 0 - M.TANK USE AND CONTENTS 439 <br /> TANK USE M Is.MOTOR VEHICLE ITUBLINU [I 1b. AMBLING [I <br /> lc.AVIATION FUELING <br /> 0 1CHEMICALPRODUCTSTORAGE [1 4.HAZARDOUS WASTE Uacd 0") 0 5.EMERGENCY GENERATOR FUEL[ILSC MULSWI 439. <br /> [1 6.OTHEEG OR FUEL [I 95.UNIINO N 0 99.OTHER(Specify): -440 <br /> CONTENTS PETROLEUM: Is.REGULAR UNLEADED 0 17MIDGRADEWIZADED 0 1b.PREMIUM UNIEADJEU <br /> [3 3.DIBSEL 0 5.JET FUEL El 6.AVIATION GAS <br /> 410. <br /> [] B.PETROLEUM BLEND FUEL rl 9.OTHER PETROLEUM S <br /> NON-PETROLEUM:0 7.USED OIL U Ia.islHANui, <br /> El 11, W. TANK CONSTRUCTION 43 <br /> OWN <br /> TYPE OF TANK I.SINGIEWALL L12.DUUJJLhWWA� U K UNKNOWN 4W <br /> PRIMARY CONTAINMENT pn'i.STEEL U �ZFIBERGLEss U o.,,L.XE,BLLADDER <br /> 0 WN <br /> ❑ 7.STEEL+INTERNAL=RQNG ❑ 95.UNKNOWN D 99.OTHER See* <br /> ARY U 7 IA <br /> ER LAS I :7ALVE 4" <br /> PLE =CONSTRUCTION <br /> OR MEMBRANE E <br /> SECONDARY CONTAINMENT [13.FIBERGLASS 0 6.EXTERIOR ME LINER U 7.xAcxErED 95 <br /> 0 <br /> 0 �0 <br /> UNSN WN �(S <br /> [1 95.UNKNO 1. U!19 0 1 :0 3 FILL SHUT 0 451 <br /> 0 8�9� T TITHE <br /> I M445 <br /> '9 <br /> OVERFILL PREVENTION & AL S 2.BALL FLOAT [1 3.FILL TUBE SHUT-OFF VALVE <br /> .U.-­ PREVENTION <br /> 7 ON EQUIPMENT <br /> E❑ <br /> ITUREMENTS IDGIMFIT FROM <br /> 7 , <br /> [j 4.TANK=TVS Q TS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> �Tp <br /> ,UC <br /> V. PRODUCT/WASTE PIPING_CONSI"4-11UN-4 460 <br /> PIPING CONSTRUCTION W.S ❑ R CTION[M CCR§206(.X3)] 459 <br /> [:1 1.PRESSURE 07 <br /> SYSTEM TYPE [1 2.GRAVITY 3.CONVENTIONAL SUCCION ❑ 4.SAFE <br /> PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS U S.FL '. Li iu-RIGID PLASTIC <br /> 0 90.NONE [1 95.UNKNOWN 0 99.OTHEp(speely): El 10.1UGIDPLASTIC 4646SECONDARY CONTAINMENT [11.STEEL U 4.FIBERGLASS -� w ..I 464< <br /> *N'30.NONE [1 95.UNKNOWN [1 99.OTHER(Specify): a644 <br /> PIING/TURBINE CONTAINMENT SUMP TYPE ❑ SINGLE WALL ❑ wUELLK WALL E?90.NONE <br /> VL VENT,VAPOR RECOVERY )AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT 10.RIGIDPLASTIC0 (Specify) <br /> PELNIARYUUNIAINMEN. '.J'�-STEEL- - -.FIBERGLASS - 4 I <br /> : i;� �;:E :��i : : : ; RL [1 4.FIBERGLASS [3 J0.RjGIDPLAST[C 90.NONE U Vy."L.(S-P.-Ify) 4544, <br /> VENT SECONDARY ..STEEL 464f1 <br /> VR PRIMARY CONTAINMENT ❑ 1.STEEL U 4.FIBERGLASS 1_1 LU.RIGID PLASTIC 90.NONH 99.OTHER(Specify) �gl <br /> 4646 <br /> VRSECONDARY CONTAIN E] I.STEEL C] 4.FISET1165' [I FO.-J <br /> RI 390NONE [3-99 OTHER(Specify) 46461 <br /> VENTP12F I ANSITION SUMP TYPE _1 1.SINGLE WALL Q 2.DOUBLE WALL YV.NONE 464i <br /> RISERPRIMARYCONIAI14�i 13 ].STEEL [14.FIBERGLASS U MkCIGWrl " IL.. �99U.NUNU - (specify) 464JI <br /> I <br /> : -------❑0---_._STEEL-------[Z_41 5-5:1i; 0�� NIEWE 1:_PLASTIC ;g i6 ;�iE 99.OTHER(Specify) 464kRISER SECONDARY KBE ; - 464kl <br /> FILLCOMPONENTS INSTALLED El LSPILLBUCT 11 2 1 yl: ;gPROTECTOR El 4.CONTAINMENT SUMP ALOAJ C 451. <br /> 1 11 1 1 1 ''d <br /> VTI.UNDER DISPENSER CONTAINMENT(UDC) 469a <br /> CONSTRUCTION TYPE SINGLE WALL [1 2.DOUBLE WALL El 3.NO DISPENSERS 90.NONE 469� <br /> CONSTRUCTION MAI� n ,� 'EL U 4.1,1BERGLASS 0 10.RIGIDPLASTIC Li w.01HER(Spec" <br /> ER DISPENSER CONTAINMENT <br /> D <br /> U� <br /> UNDER <br /> SE NT C' <br /> NO DISPENSERS 461- <br /> 0 <br /> 7 THER'S ac <br /> TO PLASTIC <br /> W 2 0 WALL <br /> 4 GL S G C <br /> RR <br /> VIII. CORROSION PROTECTION <br /> CIATAN [SOLATION 0 <br /> STEEL COMPONENT PROTECTION El 2.SACRIFICIAL ANODE(S) [1 <br /> -.IMPRESSED CURRENT [3 6.ISOLATION <br /> 0 IMPRESED <br /> AP AN <br /> Is <br /> 6 with <br /> the <br /> 7 at L. an 0 �s IMC,accurate, <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system Is compatible with the luLzardous,substance stored and that the information provided herein is true;accurate, <br /> si is <br /> and in full compliance with legal requirements. DATE 470. <br /> APPLICANT SIGNATURE��',� .2411-7 <br /> 4n. <br /> 4171. APPLICANT TITLE <br /> APPLICANT <br /> APPLICANT NAME'P-" <br /> F <br /> UP"UST-B-1/2 Rev.(12/2007) <br />