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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. Fo�ry0 �UST 7=7ciosure or removal,complete only this section and Sections 416 III,IV,and IX below) 430 ❑ 1.NEW PERMIT p}3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430, DATE EXISTING UST DISCOVERED: awn I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - - 1 BUSINESS NAME(Same as ACILffY NAMEppr DBA-Doing Business As) 3 BUSINESS SITE ADDRESS r 103 100 �4s< S�. A� � �✓ CITY � IL TASK DESCRIPTION TANK IDN 432 TANK MANUFACTURER 433 TANK CONHGURATION: THIS TANK IS 434 n �/ ❑I.A STAND-ALONE TANK /zxog S ®2.ONE IN A COMPARTMENTED UNIT. COMPIMoto fm each in =L DATE UST S/�T NSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Y X III.TANK USE AND CONTENTS TANK USE Fla.MOTOR VEHICLE FUELING O Ib.MARINAFUELING O Ic.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(6 uee UW a0 0 5.EMERGENCY GENERATOR FUEL[HSC¢25281.5(c)] 0 6.OTHER GENERATOR FUEL 0 95.UNKNOWN 0 99.OTHER (S ify): 43A CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED 0 Ic.MIDGRADE UNLEADED 0 Ib.PREMIUM UNLEADED 410 :3.DIESEL 0 5.JET FUEL 0 6.AVIATION GAS 8'.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify), 4404 NON-PETROLEUM:0 ].USED OIL 0 HI ETHANOL 4406 11.OTHER NON-PETROLEUM S CONSTRUCTION 2. TYPEOFTANK LSINGLE WALL DOUBLEWALL U 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ LSTEEL 06.INTERNAL BLADDER 444 ❑ ].STEEL+INTER LINING 0 95.UNKNOWN 0 99.OTHER Speedy): 410i SECONDARY CONTAINMENT 0 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ ].JACKETED 445 0 90.NONE 0 95.UNKNOWN 099.OTHERS ): mu OVERFILLPREVENTION LAUDBLE&VISUALALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 45x-. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 01.SINGLE-WALLED .DOUBLE-WALLED 099.OTHER 460 SYSTEM TYPE I.PRESSURE [1 ?.GRAVITY ❑ 3.CONVENTIONAL RUCTION F34.SAFE SUCTION 23 CCR§2636(03A 458 PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(SPecify): 464' SECONDARY CONTAINMENT 1.STEEL 5Z 4.FIBERGLASS 0 S.FLEXIBLE 10.RIGID PLASTIC 464b 0 90.NONE 0 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGfTURBINE CONTAINMENT SUMP TYPE JQ 1.SINGLE WALL 02.DOUBLE WALL ❑ 90.NONE 4644 VL VENT,VAPOR RECOVERY(VR)ANDRISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS IO.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4 464e1 VENT SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC a 90.NONE 99.OTHER(Specify) a64f 464n VR PRIMARY CONTAINMENT 0 (.STEEL 04.FIBERGLASS 0 10.RIGID PLASTIC CY,90,NONE 99.OTHER(Specity) 464r 46491 VR SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 10,RIGID PLASTIC 90.NONE 13 99.OTHER(Specify) a6M 461h1 VENT PIPING TRANSITION SUMP TYPE 171 I.SINGLE WALL 2.DOUBLE WALL 990.NONE 4641 RISER PRIMARY CONTAINMENT 1.STEEL LJ 4.FIBERGLASS LHJ 10.RIGID PLASTIC U W.NONE LJ W.OTHER(SPmify) 4641 464'1 RISER SECONDARY CONTAINMENT El 1.STEEL 4.FIBERGLASS El 10.RIGID PLASTIC 90.NONE 0 W.OTHER(Specify) 4641 a64kl FILL COMPONENTS INSTALLED .SPILL BUCKET QE3.STRIKER PLATFJULI J IOM PROTECTOR 0 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL 0 2.DOUBLE WALL 0 3.NO DISPENSERS ❑ W.NONE 46A CONSTRUCTION MATERIAL ❑ 1.STEEL It 4.FIBERGLASS 0 10.RIGID PLASTIC ❑ W.OTHER(S ity) 4696c VDI. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448' DC. APPLICANT SIGNATURE CERTIFICATION: I c T sys m is compatible with the hanrdoue subspace stored aad that the information provided herein is true,secants, tofu m ' nce With IeRal requirements. aro. APPLICANT SIGN TU DATE S"-/-7-/0 a]I 4 . APPLICANT NAME(prior) � / / APPLICANT TITLE 7 jjyf UPCF UST-B-112 �I'f( " Rev.(11=007)