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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form r US TYPE OF ACTION (Check one item only. For an UST pe ane PERNBTor removal,complete only this section 5.CHANGEi1 INFORMATION IV and I �I ) 4w ❑ I.NEW 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 43M DATE UST PERMANENTLY CLOSED: IDATE EXISTING UST DISCOVERED: I. FACILITY INFORMATION i [FACILITY ID#(Agency Use Onty) Val �j SINESS NAME(Same as FACILITY NAME or DBA-Doing Business As)� ' � �INESS SITE ADDRESS " CITY IL TANK DESCRIPTIO 432 TANK MANUFACTURER 413 TANKC'ONFIGURATION: Tin TANK IS 436 TANK[D#•r,A OJ��SS� ❑1.ASFANO-ALDNE TANK [92.ONE D3 A COMPARTMENTED IItdR. t11�-YLO W Yl Co ie.eme 437 DATE UST SYSTEM INSTALLED 433 TANK PACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT TANK USE AND CONTENTS TANK USE )LI&MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc. M AVIATION FUELING a3v ❑ 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(lodIIdo I dUp ❑ S.1]�RGENCYGEFIERATUR FUEL[RSC§25291.5(c)1 43% ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(S ): CONTENTS PETROLEUM: ❑ REGULAR UNLEADED ❑ 5- M1DGRADE UNLEADED U1 lb-PREMIUM UNLEADED 3. 440 3 DIFCFI [I5 JEF F(1FL n 6.AVIATION GAS 4404 ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM iY. NON-PETROLEUM:❑ 7.USED OIL u I0.ETHANOL �4 ❑ 11.OTHER NON-PETROLEUM S IV. TANK CONSTRUCTION I.SINGLE WALL 2 DOABLE WALL 95.UNKNOWN em TYPE OF TANK 444 PRIMARY W i.STEEL ❑ 3.FIBERGLASS U 6.INTERNAL BLADDER eats ❑ 7.STEEL+BTIptNAi.LIMNG ❑ 95.UNKNOWN ❑ 99 OTHER : 04S SECONDARY CONTAINMENT1.STEEL ❑3.F®ERGLASS ❑ 6.E1TERIORMEMBRANELINER ❑ 7.JACKETED 40.TI 90.NONE ❑ 95.UNKNOWN 99.OTI�R(S ): esz OVERFILL PREVENTION 11.AUDIBLE s VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE U 4 TANK MEM REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT)WASTE PIPING CONSTRUCTION .w PIPING CONSTRUCTION 01.SI GL&WALLED 2.DOUBLE-WALLED ❑99.OTHER 459 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVTPY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION v CCR 9as35(m )I 444 PRIMARY CONTAINMENT ❑ L S J 1:hL _W 4.FIBERGLASS ❑ 8.TLE)®LE (] 10.RIGID PLASTIC ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specdy): 4641 4.FBFRGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 SECONDARY CONTAINMENT ❑ t.STEEL 464c ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTFIER(S )- a6ad PIPINGfrURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE VL VENT,VAPOR RECOVERY(VR)AND RISER I FILL PIPE PIPING CONSTRUCTION 46. 4.FIBERGLASS ❑ lu-muIDPLAS11C 90.NONE. 99.OTHER(SPMIY) VENT PRIMARY CONTAINMENT ❑ 1.STFm. abael 161E VENT SECONDARY CONTAINMENT I.STEEL LI 4.FIBERGLASS U Iu.RIGIDPLASUC 90 ONE 99.OTHER(Specify) eban VR PRIMARY CONTAINbffNT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4649 ty) 464 1 64n VR SECONDARY CONTAINMENT ❑ 1.STEEL U4.FIBERGLASS 10.RIGID PLASTIC 90-NONE 99.OTHER(Specify) 46ih1 4611 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL ❑ Z.DOABLE WALL -90.NONE 464, RISER PRIMARY CONTAINMENT 1.STEEL ❑ 4.F®ERGLASS 10.KIQHIJM SIK, -.NONE 99.OTHFR(Sp ." d6r1 4694 RISER SECONDARY CONTAINA�NT 1.STEEL ❑4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTIRER(Specify) 46191 FILL COMPONENTS INSTALLED 1.SPILL BUCKET - 3.STRIKER PLA17'lB0'fTlN,t PROTECTOR ❑ 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE JI-i SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE CONSTRUCTION MA7ERIAI- ❑ 1.STEEP. E3 4.FIBF7RGLASS 1310.RIGID PLASTIC ❑ 99.OTFffR �(S ) 4696, VIII. CORROSION PROTECTION us STEEL COMPONENT PROTECTION Z.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT Nr6.ISOLATION , Di. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance smrad and that the information provided herein is JYM%ccurate, mod in full compliance with leital requirements. - oro yICANT SIGN DATE S../ APPLICANT NAME(pnnt) APPLICANT TITLE eCV91s G7 V Y Rev.(I 2007) UPCF UST-9-L2 t