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I Vk lqwlve�"o /,/10/. -L f ✓NIFIED PROGRAM CONSOLIDATED Fi. 4 /Pl rJ .735a,? UNDERGROIJND STORAGE TANK I L OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) 4� TYPE OF ACTION (Check one item only. Form UST permanent closure or removal,complete only this section and Sections I,II,Ill,IV,and IX below) 430 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 410' DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID N(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSIN� 'SS�'O DD (�O� •Z-i,� 103 CITY �.\Oo- IN IL TANK DESCRIPTION TANK ID H 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 1 51q.A STAND-ALONE TANK l ❑2.ONE IN A COMPARTMENTED UNIT. Com Inemc eforeachcom mtmlbe,mii DAT STEM INSTALJLED 435 TANK C ACTTY IN GALL NS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 O Ooa t III.TANK USE AND CONTENTS TANK USE gl..MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING 0 Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE n Clado Uxd Oa) 0 5.EMERGENCY GENERATOR FUEL[RSC f2S281.5(c)] ❑ 6.OTHER GENERATOR FUEL 0 95.UNKNOWN 0 99.OTHER (Specify): 439s CONTENTS PETROLEUM: 9:7Ia.REGULAR UNLEADED ❑ tc.MIBGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 0 3.DIESEL ❑ 5.HET FUEL ❑ 6.AVIATION GAS 0 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440. NON-PETROLEUM:0 7.USED OIL 0 10.ETHANOL 0 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION TYPEOFTANK 0 1.SINGLE WALL Eja.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL W3.FIBERGLASS 0 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN 0 99.OTHER (specify): 444. SECONDARY CONTAINMENT ❑ L STEEL 3.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER 0 7.JACKETED 445 ❑ 90.NONE t 95.UNKNOWN 099.0THER(Specify, 415. OVERFILL PREVENTION 103.FILL TUBE SHUT-OFF VALVE.AUDIBLE&VISUAL ALARMS 2.BALLFLOAT 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED &Q.DOUBLE-WALLED 099.OTHER 460 SYSTEM TYPE .PRESSURE El2.GRAVITY [13.CONVENTIONAL SUCTION 0 4.SAFE SUCTION(23 CCR 42636(.x3)) 458 PRIMARY CONTAINMENT 1.STEEL FIBERGLASS 0 8.FLEXIBLE 0 10.RIGID PLASTIC 464 0 90.NONE 0 95.UNKNOWN 0 99.OTHER(Specify): 464= SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 0 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 0 90.NONE 95.UNKNOWN 0 99.OTHER(Specify): 464c PIPING/[URBINE CONTAINMENT SUMP TYPE 0 1.SINGLE WALL Et.DOUBLE WALL ❑ 90.NONE 46id VI.VENT,VAPOR RECOVERY(VR)AND RISER/FELL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 54A.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464. 464.1 VENT SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL [-4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) a64g 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL &:.4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 4646 464hl VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL .DOUBLE WALL 0 90.NONE 464i. RISER PRIMARY CONTAINMENT V4�1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464j 4641 RISER SECONDARY CONTAINMENT ❑ 1.STEEL E%4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 4641 464kl FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL 0 3.NO DISPENSERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL 0 1.STEEL .FIBERGLASS ❑ M RIGID PLASTIC 0 99.OTHER(Specify) 4696 VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION 0 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT b.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' full compliance with legal requirements. APPLI ANT SI lCI-Q� 1 DATE 23 1 ' 470. APPL[CAJ(f UPCF UST-BB-1/2 r Rev. IV2007)