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05/20/2009 13:53 2094640'38 ENVIRONMENTAL Hir".TH PAGE 03/04 UNIFIED PROGRAM CONSOLIDATED FORM UNDARGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION One form US E OF ACTION (Cheek one item only. For UST permanmt closure or roaovnl, c0mp16te only thin l"I and Seet1eR91, D, III, TV, DC below) and 1. NEW PERMIT 3. RENEWAL PERMIT ❑ S. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON STfE. UST REMOVAL DATE VST PERMANENTLY CLOSED; ,CCIJfXJ 1 DATE EXISTING UST DISCOVERED; ( t-AII oob 1. FACILITY INFORMATION FACILITYfD3(APmq Uas Only) _ 1 BUSINESS NAME (Sane u FACILITY NAME or DBA -Doing Burims9116) V C4.j 1 BUS S S L Ia CITY la IL TANK DESCRIPTION TANK IDN U0 TAMC MANUFACTURER ax] TnN� CONPIOV11AT10N: THIS TANK IS 1/ -3 9- i `j $ rj s i31 a STAND-ALONETANR ��/� � ❑2.ONBNACOWARTMgNTgDUNyr. DATE UST SYSTEMS iDI$1'n[„j,EED ua T L�'VVV Benne efereeA mn IN c (/,VrA, ANK CAP CFfY MOALLON$ NUMBER OP COMPAA N THE UNIT av (/ ui, AAdv.�c U� LPiND CONTENTS TANK USE A34,MOTOR VEHICLE FUELING ❑ lb.MARINA PUELING i] Ia AWATIONFUELNO I71.CHEMICAL PRODUCT STORAGE 439 ❑ 1. HAZARDOUS WASTE(ekdel U.don) ❑ 9.EMEROENCYGENERATORFUELFISCtTs11N11) 0 GoTRERGENERATOR FUEL ❑ 95. UNkNOWN 99.OTRSR Bei CONTENTS PETR016UM: ❑ Is. REGULAR UNLEADED ❑ I, MIDGRADE UNLEADED O MPREMIUM UNLEADED �9 0 D.DISSEL ❑ S,]ETFUEL 1] 0. AVIATION OAS ❑ 1. PEMOLQUMBLBND MEL 13 P. OTHER PETROLEUM NON•PUM ILEUM: ❑ 7. USED OR ❑ 10. ETHANOL 13 II.OTNFJI NON.FIITROLEVM N . IV. TANK CONSTRI CT1 4`141, TYPE OFTANK SINGLE WALLLDOUBLE WALL II.UNKNOWN PRIMARY CONTANMENT ❑ 3. FIBERGLASS W .STEEL o CADGER 7. STEE1,+rIn"NAL 1•iNIN 95.UNKNNOWN BR >N OTHER S SECONDARY CONTAINMENT 1. STEEL M 7. FleE11GLASS IA ❑99.OTkIER09 MEMBRANE LINER 7. rACR67ED .NONE 96.UNRNOwN OVE LLP FND I,AUOTIME.a VISUAL ALARMR1.gALL PLOAT "u/.TANK ]. FICA TUBA SHUT•OPP VALVE CI MEETS RIRUTAAMIINT$ POREXEMPT)ON FROM OVERFILL PRRVENTION SVIPMENT ' V. PRODUCT/WASTE PIPINGCONSTRI)CTION 1.SNGLE•WnLLEO 2DOUBL6WALLBn ❑99.O7HFA SYSTEMON57RlKTiON $YSTEMTYPB I. PRESSURE z GRAVITY NVENTIONALS CTI 1. SAFE SUCTION LtXR e5 . PRIMARY CONT MSNT / I. STEEL ❑ 1. FIBERGLA99 ❑ 9, FLEXIBLE 10. RIGID PLASTIC R/ ❑ 90. NONE ❑ 9S. UNKNOWN ❑ MOTHER cel IPI SECONDARY CON AINMfiNT 1.9TEELLJ 1, FIBERGLASS 8. FLBXIBLE 10, RIGID PLASTIC � NONE [] 95. UNKNOWN O 99.OTHER 9 tN 91pMCdTURBiNg CONTNNMENT SUMP TYPE 9616 , 1.SNGLE WAµ I. DOUBLE WAµ 171 90. NONE VI. VENT, VAPOR RECOVERY )'AND RISER / FILL PIPE 46W PIPING CONS'CRUCTION VwTpRI U1. $TEE[. LPIBEAGLA$$ IO. RIGID PLASflC O,NONQ 99.OTHER (s"I h) I VENTS NDAAYCONTANMENT I�STEEL �, FIBEROLA94 10. RIGID PLASTIC ,NONE 99.OTIIBR(SpalTy I6I( VRPRTMARYCONTAINMENT ❑ I.SiETu, D1. FIBfiitOL 10.IUOlp PLASTI!I: IV N E auR 99.0 k(9peeiry) VRSOCONDARYCONTAnOAEIFT L. STEEL t. NBEAGLASS 10. RIGID PLASTIC NtME let 1 . 99.OTHER(Spwify) VENT TPN TRAN$TON SUMP TYPE I.SINGLEWALL LDOURLEWALL I INbl NONE RISER PAIMARYCONTAINMFNT I. STEEL a. FIBERGLASS 10,111.1010 PLASTI NON164 _ RISERSECONDARY CONTAINMENT �. 1. $TEFL 1.FIBERGLASS 10.111010 PLASTIC 4 1 NONE 99.OTNfiR(Spodry) 11µ COMFON6NT6 INSTALLED 1.9P1µ BULKfi7 3.91R1KBR PLATFIBO I OMPR07ECTORa. I6I5 CONTAINMENT SUMP VII. UNDER DISPENSER CONTAINMENT (UDC) tlI CONSTRUCTION TYPE ❑ 1.$NOLEWAµ [3 z. DOUBLE WALL [] 3.N0 O1SPPNSER$ CONSTRUCTION MATE0.fAC 90. NONE uea I. STEEL I. FIBERGLASS 10. RIGIDPLAS77C ❑ 99.OTHER S asbe VIII. CORROSION PROTECTION . STEEL CONUONENTPR07ECTION O 2. SACR6[CIAL ANCONS) 101. IMPRESSED CURRENT ❑ 6.ISOLATTON IX. APPLICANT SIGNATURE CERTIFICATION: I certifylthis UST /y/rem 6 pom firms with the haRardoul nEbrGRe6 stored and thgt the In[6rmgtfm III In - cn full 1111111m1111111m eieh 11 r Nrcm9np. prmMed hml. v tne, aagnte, APPLICANT SIGNATURE _ DATE APPLICANT NAME (print) tCTT}yE n. Z VPCF UST -13 - U2 FA Rev. U2ldon