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L^ ,4- -7A 5 0 QVR' UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections L II,III,IV,and IX below) 430 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 630a I DATE EXISTING UST DISCOVERED: X06 I. FACILITY INFORMATION r2 / Q 9' FACILITY ID R(Agency Use Only) i BUS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 ^ LA x BUSPMSS SITE ADDRE tai CITY IN IL TANK DESCRIPTION TANK ID# ' 432 TANK MANUFACTURER 433 ANK cGmGuaAnoN: THIS TANK IS 434 .A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED IlN1T. Com lets we p,e far mchoo v tis the wit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 Z 17 C7 27 III.TANK USE AND CONTENTS TANK USE -IQ la MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ le.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(3adW Umd Oil) ❑ 5.EMERGENCY GENERATOR FUEL R15C§2528I.5(c)1 ❑ 6.OTEERGENERA RFUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: I. REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 19 3.DIESEL ❑ 5.TET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): a40a NON-PETROLEUM:❑ T USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS a4ro IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL [195.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): a44a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED ass ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTBER(Speci : 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS LI 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 451 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 123 CCR§2636(aX3)1 458 PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEMLE ❑ 10.RIGIDPLASTIC d646 ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Spec*); ): a64 PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE a6a4 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL W,4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT El I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f a64ti VA PRIMARY CONTAINMENT 1.STETS. 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Speafy) 4648 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL S,4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 46ah 464h1 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL2.DOUBLE WALL El 90.NONE 4641. RISER PRIMARY CONTAINMENT ISL1.STETS. ❑ 4.FIBERGLASS IN 10.RIGID PLASTIC ❑ 90.NONE U 99.OTHER(Specify) a64j 4641 RISER SECONDARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464ki FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKERPLATEBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL T5,2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469% CONSTRUCTION MATERIAL ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 9696< VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRITICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.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 in full compliance with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME(print) 4n. APPLICANT TITLE 472, UPCF UST-B-12 Rev.(122007)