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05/20/2009 13:53 2094'- '1138 ENVIRONMENTAL -ALTH PAGE 03/04 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERNIITAPPLICATION- TANK INFORMATION oneIorm crus TYPE OP ACTION (Cheek one item only. Fora UST permanent elost" Or removal, complete only this action and Sections I, E,114 TV, and IX below) uA y�S.�+�1. NEW PERMIT 3. RENEWAL PERMIT Q 5. CHANGE OF INFORMATION I l A. TPIUVf1R 6pYitM r'r netme -- -- ..�- ruuc .U314 MVVA DATE UST PD•RMANENTLY CLOSCD: ,Cp><;YJ 4 DATE EXISTING UST DISCOVERED: (/,,,/,r yr� uo6 I. FACILITYRYFORMATICN FACILITY 1D A(Mgmry Ui¢ Qnly) BUSINESS NAME (Same m FACILITY NAME er DBA-DolnitBusiiess As) f T1 V C�9rJ / 7 BUSNE, $ C / im CITY ST G,�7 f2 92 IN IL TANK DESCRIPTION TAMC IDA 432 TANK MANUFACTURER 4A1 Tnn3 CONRQO Aticim THIS TANK IS 414 39 OS/ d / B+n STAN ALONRTANX �P(%�/�%Q17 -1 Qi.eONBw A COMARTMBNTED NUNIT` DATE VST Sv'"" KN(/c✓ 4a TANK CAPON GALLONS NUMB ER OP COMPAR N }N'THEUNTT (/NK!✓(/ t- ui AAI,TANI�USXrAdVnCONTENTS TANICUSE MOTOR VEHICLE PUELING 0 16.MARINA PUECNC ❑ la AVIATION FUELNO ❑ 3.CHEMICAL PRODUCT STORAGE 419 ❑ 4. HAZARDOUS WASTE(Imldn UadOn) ❑ J.EMERGENCYGENERATORFUELp=i=ls(,)1 ❑ 6- OTHER GENERATORFUEL 0 95. UNKNOWN ❑ 99.O771HR CONTENTS PBTROL6VM: ❑ Is. REGULAR INIFADED ❑ Ic. M1DGRADELNLEADED ) 0 Ib.PREMI UNLEADED 419. ❑ 3. DIESEL 0 J•)�.Pl1L� ❑ 6,AVIATION GAS ❑ S. PBTROLBUM BLEND PUSL ❑ P,OT•tER PETROLEUM u0 'I ; N 41 NON-PSTROLEUM:O 7. USED OIL ❑ 10. ETHANOL 4400 II.OTHI?R NON•PBTROLEUM tti 4406 N,. TANK CON$TRVCTTON TYPE OP TANK $NGI.II WALL LDOUHL.e WALL 9J. UNKNOWN PALMARY IbNTAINMENT ,57EE1, ❑ 7, FIBERGLASS cal 6,IMRRNAL BLADDAR 7. STEEL -+INTERNAL LINING 095. UNKNOWN 99, OTHER 444 eiS : SELUNDARY CONTAINMENT O I. STEEL 1. FIBERGLASS ❑. E%TMAANELLINER 6-RATRRIOREMB M 7. lACKETID 4444 . NONE 95 -UNKNOWN S I OVERFILL PREVENTION 1,AUD18LEk VISUAL ALARM& f.8Ai1, P[OAT NS UL 1. FMLTU88SHUT-OPP VALVE NK - / l]4. TAMEETS RE,QUHIEMENTS FOR EXEMPTION PROM OVBRMLL MEVENTIONQv➢MLNT E y� I. V, PRODUCT/WASTE PIPING CONSIxuL:jION PIPNG CONSTRUCTION T,SINGLE-WALLED IDOURTFWALLSD 099.OTHEA SYSTEM TYPE I.➢RE$SI)RE 9.GRAVITY PRI MARY COMAIN'MENT NVENTIONAL SUCTION A,$AF65UCT10N s3 CCR x61 .1 / LSTEEL 13 4.FIBERGLASS 0 8. FLE%ISLE ❑ 460 45. d10. R1GID PLASTIC 0 90.NONE 0 95. UNKNOWN 1399.OFF ER Mb: 4N SNRY CONYAfNnI T ECODAEN1. STEEL 4. FIBERGLASS a, FLE%THEE ❑ 10. RICTD PLASTIC 4Ay NONE ❑ 95. UNKNOWN ❑ 99.OTHER ($ tti PIPM(i?URRIM±gpNTNNMBNT SVAIP TY➢L• 46+6 , 1.SNGLE WALL 2. b0Ubl.Rzl L 171 90. NONE VL VENT, VAPOR R$CO VERY (YR) ANp R[SER. / FII L PIPE PIPING 4GE CONSTRUCTION VENT PRTMARY CONTANMp)Tr 1.$TEHL 1. PI8$RGLASS 10. RIGI➢➢LASTICo.NONH 99. OTHER ($peeiry) VENT SECONDARY CONTNNMENT 464E 1. STEEL 4. FIBEILGLA33 10. RIGID PLASTIC .NONE 99. OTHER 9 cl (� ry) 44641[ VR PRIMARY CONTAINMENT Q I. MEL 4. FIBERGLAS 0 10. RIOID PLASTIC N E 46411 99.OTHEA(3pee(/y) VR SECONDA0.V CONTARtAttNT I. STEEL 4. FIBt]tGLASS 10. AIOID PLASTIC 464, I .NONE4m 99. OTH61t(9peGry) VENT PJPNGTRANSI'GON $UMP TYPH 1.$NGLE WALL iD0UBL6 WALL 461E 4&61 RISER PALMARY LUNTAINMFM LSTEEL /. F]efiROLASSU 10, AIOID PLASTIC NONE 99.OYHER (9peeiry) 46L WSERSEC4ANDARYCONTAINM9N7 I. STEEL 4. FIBERGLASS 10. RIGID PLASDC ,NONH 99. OTFiER(Epenf AMk FILLCOMPONENTS INSTALLfiD 1i 1.9PILL BUCKET 3. STRIKER PLATi/BOTTOM }AOTECTOA A.CON7ANMEM SUMP 46441 VII. UNDER DISPENSER CONTAIN1GiENT N n51e< CON$TRUCDON TYPE• ❑[,SINGLE WALL 02. DGVBLEWALL 03. NO DisygN$$RS ❑ 90. NONE CONST0.UCI']ON MATT -RUL 0 1.9TT?E. 0 4, FIBERGLASS 4c9r 10. RiGiD PLASTTC _ ❑ 99. OT5IBR 5 eM 4cPEc VIII. CORROSION PROTECTION' . STEBLCOMPONENTPRO'TBCTTON 02. SACRIFICIAL ANODE( U 4, IMPRESSED CU. RUNTI ❑ 6- ISOLATION u.. IX. APPLICANT SIGNATURE CERTIFICATION: I cern that thb UST system tom [rem with the hAZArdoeunbstAnce mored and that she Into P PCT.rmatl9n provided herein h hen • and In htl m Itnnce with mi +1 r rcmente. amuTite, APPLICANT SIGNATURE - DATE x.410. APPLICANT NAML•(prim) / / nl. iC 7117,$ 4n, UPCF UST -11 - 1/1 Rev. (122007)