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( Dec 12 08 03:45p John Johnson - 91F-443-6225 p.4 -rA- 5 -7q6-q J7 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(ome ram PerusT) OFACTION (Chmkoneitcmonly. Form UST peuarrentclosl orr val,complete only tads sation end Sections L 7 IN,IV..A IXbelow) 454 I.NEWPERMTT IN 3.RENEWAL PERMIT 0 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLDSE 1. � I DATE EXISTING UST DISCOVERED: 43m I. FACt1:FCY INFORMATION FACILITY ID S(ARemy Uae OWly) BUSINESS NAME(Same ae FACILITY NAME cu DBA-Doing Buzims As) 3 r :&k N TI BUSINESS SITE ADDRESS O Ips CITY toa IL TANK DESCRIPTIO TANK IDN 432 /TA1NK MANUFACTURER 433 TANAc,N GURAnGN:T,,,T"X,, 4M r I LOPLt-2.m TIB .0�1.A SfAND-ALDNE TAN[ pre M h 11 4cR2.ONEM A COMPA0.TME4Tffi5 UNIT. �044�1aWJ Nm Neax brach in tae miL DATE TSYSTE INSTALLED 435 TANK CAPACITY INGALLONS 454 NUMBER OF COMPARTMENTS IN THE UNrr 437 /O ID.TANK USE AND CONTENTS TANK USE Ia.MOTOR VF30CLE FUELMG O Ib.MARTNAFUELfNG 0 Ic.AV1ATIONFUBLING 439 03.Q lCALPR(DL=STORAGE 04.HAZARDOUS WASTE(Tglpdal Ul) ❑ S.EMERG&NCV GENERATOR PIIFJ.(xscf2slals(c)) Cl GOTHERGENERATOR FUEL 0 95.UNKNOWN 0 99.OTHER 41% CONTENT'S PEIROLFum 0 Ia.REGULAKUNLEADED 0 Ic MIDGRADE UNLEADEDO.PRFMIUMUNLEADED MO 03.DIESEL 05.JET FUEL 04_AVIATTONGAS 0 8-PETROLEUM BLEND FUEL 0 9.0THIX PETROLEUM (S mi 4a9a NON-PETROLEUM:(] 7.USED On. 0 IO.EMANOL 11.OTHER NON-PETROLEUM wi : 44ah IV. TANK CONSTRUCTION TYPE OF TANK 11I.SINGLEWALL 2.DOl1BLEWALL 095.UNKNOWN 945 PRIMARY CONTAINMENT [II.STEEL .FIBERGLASS U &INTERNAL BLADDER 44{ 117.STEEL4BSFERNALLPIING 11 ".UNR40WN 099.amm (Smmaw SECONDARY CONTARAtEN'T 0 L STEEL 3-FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER 0 T.JACRETID 445 ❑ 9o.NONE C 95.UNKNOWN 099.OMER(Spcei k NSa OVERFILL PREVENTION 3rl.AUVJBLE.VWUALALARMS LL BAFLOAT b 3.FILL NEE SHUT-OFF VALVE 432 13 4-TANK MEETR REQUIREMENTS FOR EXEMPITON FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONSTRUCTRN I.SIMILE-WALLED 2.I30UfiLEWALLED ❑99.OTHER im SVSTE ,I I.PRESSURE ZGRAI FTY 03.CONVENTIONAL SUCTION 4.SAFE SIICHON Ra faa 4% PRIMARYCONTAMMWI Li I.STEEL 4.FIBERGLASS 0 B.FL MBLE 090.NONE 95.UNKNOWN 099.OTIffR(spxify ❑ Ip.RIGID PLASTIC a5ao SECONDARY CDNI'ADB,@NT I.STEEL 4.FIBERGLASS U &FLEXIBLE 0 1C.RGIp PLASTIC 4690 090.NONE 095.UNKNOWN 099.OMER(Spadlyk 4wc PIWNG/IURBLNE CONTAINMENT SUMP TYPE OI.SMGLE WALL 2.1JOUBLE WAIL ❑ 90.NONE 4w4 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENTPRIMAKYCONTATNMENT U I.STEEL X4.FIBERGLASS 0 IRRIGIDPLASTTC 0 SDNONE D 99.OTHER($p acify) 464 4 VENTSECONDARY CONTAMhfENT LJ I.STEEL PL,4.0BORGLASS 0 IO.RGID PLASTIC 0 9Q NONE 99.OITiER(Specify) 4wr wn VR MIWARY COMAD4MENr ❑ I.STEEL 4.MOFAGLASS 10.RIGID PLASTIC 9p.NONE 99.OTHER(Spec fy) 4wg VKSECONDARYCONTAINME.NT 0 (.STEEL 4.FIBERGLASS IO.RIGIDPLASITC 46491 90.NONE 99.OTHER(SlWcify) awn IP0I4 M VENT PRJMJ RANSITIONRIIMPTYPE 1.SINGLEW - 2.DOUBLE WALL 9O.NONE 4wi, BSER PRIMARY COMAINflENT I.$TEFL 4.FiBERGLA55 IO.RiC1D PLASI7C W-NONE 0 OOTHER(Seccify) 464j 961'1 RJSERSELaNDARY COM'AMMFM ❑ I.STEEL 4.FIBEAGLASS IO.RGID PLASTIC 9p.NONE 99.OTHER(Speciry) 464k 46 kl FB.L COMPONENTS INSTALLED 1.SPILL BUCRST - 3.6TRIKFA PLATEMOTTOM PROTECTOR A CONTAMMFM SUMp 451rc VQ,UNDER DISPENSER CONTADVMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WAIL, 2.DOUBLE WALL 0 S.NO DLWENSERS 0 90,NONE 449a CONSTRUCTION MATERIAL 01.STEEL RL FFIBERGLASS UO.R 3W PLASTIC 99.OTNER(S ihN 449 VIII.CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFIaAL ANODE(S) 0 4.IMPRESSED CURRENT ❑6.ISOIATION ae. IX. APPLICANT SIGNATURE CERTIFICATION:I Certify that this UST system is compadble with the hazardous suha=m Stored Rud that Bre 1uf0emation ProPMed bsreln B woo,mcurale, adm NII cvmsxglxn with legal requilemeam APPLICANTSIGNATURE C DATE 47a APPLICANT NAME(print) n 4T1' APPLICAM a>4 Y7 YT !7 On i i1 . UPGF UST-E-1/2 Rn.(12rM"