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ED PROGRAM CONSOLIDATED F �[ � I�ZZ OPERATING pE UNDERGROUND STORAGE TANK 9�Cg �q TYPE E ACTION (check one item onl . RMIT APPLICATION-T X 1.NEW PERMIT Y For an UST permanent closure or removal,complete only INFORMATION(One form per UST) 6.TEMPORARY UST CLOSURE 3'RENEWAL pERMTT Y this section and Sections II,III,N DATE UST PERMANE LY CLOSED: T UST PERMANENT CLOSURE ❑ 5.CHANGE OF and IX below) 430 ONSITE ❑ &UST INFORMATION aY DATE EXISTING UST DISCOVERRED: FACILITY m k(Agency Use prr7,� I. FACILITY INFORMATION 4306 BUSINESS NAME(Sarre as FACILITY NAME or DBA- o Tower#876 Doing Business As) - 1 I 1 BUSINESS SITE ADDRESS 14000 E.H 88 3 103 CITY TANK ID 9 IL TANK DESC 10.1" ford 104 2 432 TANK MANUFACTURER 43�TION J� I I`/ Un TANK CONFIGURATION: THIS TANK IS N- I A I b�(v b X LAS D- NE TANK 434 DATE UST SYSTEMINSTALLED 43s ❑2.ONE IN A COMPARTMENTEp ON TANK CAPACITY IN GALLONS 436 Com Ire ove a for each com unm in thTre unit. 8,000 NUMBER OF a COMPARTMENTS IN THE UNIT I 93] TANK USE x ]a.MozoR vEII cLE FUELTNc III. TANK USE AND CONTENTS ❑ 3.CHEMICAL PRODUCT STORAGE O 1b.MARINA FUELING ❑ 6.OTHER GE HAZARDOUS WASTE ❑ 1c.Al 111 11 FUELING CONTENT$ NERATOR FEEL ❑ y5. AZARUNKNOU (Includes U,.d Oil) ❑ 5.EMERGENCY G 439 PETROLEUM° ❑ ] WN a.REGULAR UNLEADED ❑ 99.OTHER (Specify)GENERATOR FUEL[HSC§z5za L5(c)] ❑ 3.DIESEL ❑ la MIDGRADE UNLEADED x !b.P 439a ❑ 8.PETROLEUM BLEND FUEL ❑ 5.JET FUEL REMIITM UNLEADED 3% ❑ 9.OTHER PETROLEUM ❑ 6.AVIATION GAS NON•PETROLEUM:❑ 7.USID OIL (Specify); ❑ 11.OTHER NON-PETROLEUM(S ❑ 1).ETHANOL a4oa N. TANK CONSTRUCTION 440b TYPE OF TANK ❑ 1.SINGLE WALL x 2.DOUBLE WALL PRIMARY CONTAINMENT x 1.STEEL ❑ 95.UNKNOWN` ❑ J.FIBERGLASS ❑ 6.INTERNAL BLADDER a43 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER 4a4 SECONDARY CONTAIIAfLIJJT X I.STEEL ❑ 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LIFTER ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHERS c' ❑ 7.JACKETED a4s OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ( ce �x 4a5a ❑ 4.TANK MEETS RE ❑ 2.BALL FLOAT x 3.FILL TUBE SHUT-OFF VALVE 452. QUII2EIviQ4TS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONS TRUC TION PIPING CONSTRUCTION ❑1.SINGL�WALLED x 2.DOUBL&WALLED ❑99.0THER 460 SYSTEM TYPE x 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTTON ❑ 4,SAFE SUCTION[23 CCR§2636(ex3)] 450 PRIMARY CONTAINMENT ❑ I.STEEL X 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.Ocify); THER(Spe46ya SECONDARY CONTAINMENT [11.STEEL x 4.FIBERGLASS Ela.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/71 CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464a VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL x 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.O'ITIBR(Specify) ab4e VENT SECONDARY CONTAINMENT ❑ 1.STEEL x 4.FIBERGLASS ❑ !0.RIGID PLASTTC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464n VR PRIMARY CONIADIMENT ❑ I.STEEL X 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 Al VR SECONDARY CONTAINMENT ❑ I.STEEL X 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mh 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL x 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT x I.STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 4641 RISER SECONDARY CONTAINMENT' ❑ 1.STEEL z 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 4Mkl FILL COMPONENTS INSTALLED x 1.SPILL BUCKET x 3.STRIKER PLATE/BOTTOM PROTECTOR x 4.CONTAINMENT SUMP 451a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE X 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL x 4.FIBERGLASS ❑ l0.RIGIDPLASTTC ❑ 99.OTHER(Specify) 4696-c VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448, LY. APPLICANT SIGNATURE CERTIFICATION: 1 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 S 470, 7- O APPLICANT NAME(print) Dulcinea Webb 471. APPLICANT TITLE Compliance Manager 472. UPCF UST-B•1/1 • Rev.(12/2007)