BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

LX�II J UNIFIED PROGRAM CONSOLIDATED FORM JJ UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. Foran UST Permanent closure or removal,complete only this section and Sections 1,11,III,IV,and IX below) 430 01. L 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: moa DATE EXISTING UST DISCOVERED: Joe I. FACIIdTY INFORMATION FACILITY ID#(Agency Use Only) BU;gSS NAME(Same es FACILITY NAME or DBA-Doing Busimsv As) `e11/w:r-r BUSINESS SITE ADDRESS sa.�c.. Lt.., -2- CITY �� IL TANK DESCRIPTION TANK ID# 4l2 TANK MANUFACTURER 433 TANK CONFlGURATION:THIS TANK IS 4 1.A STAND-ALONE TANK / LJ 2.ONE IN A COMPARTMENTED UNIT. DATE UST SY TEM TALLED 435 a`°"i r°"a°b +^aw wtic TANK CAPA rfY IN GALLONS 4J6 NUMBER OF COMPARTMENTS N THE UNIT 437 d M.TANK USE AND CONTENTS TANK USE y❑�a Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING 11 Ic.AVIATION FUELING 4J9 .)a 3.CHEMICAL PRODUCT STORAGE [34.HAZARDOUS WASTE(6 J°4e Us,Oil) 135,EMERGENCY GENERATOR FUEL[HSC 1=81.401[3 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (S i ); g3ga CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ic,M[DGRADE UNLEADED ❑ Ib.PREMNM UNLEADED r �^ 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 1 ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM g aw a/ 040a I�1 I2 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL J 11.OTHER NON-PETROLEUMS III 4406 TYPE OF IV. TANK CONSTRUCTION PRIMARY CONANK I.SMGLE WALL � 2.DOUBLE WALL ❑ 95.UNKNOWN PRLMARY CONTAINMENT L STEEL ❑ 3.FIBERGLASS 44J ❑ 6,INTERNAL BLADDER 7.STEEL ❑ 95.UNKNOWN ❑ 99 OTHER (S SECONDARY CONTAINMENT L STEEL ❑3.F®ERGLASS �5 ❑ 6.EXTERIOR MEMBRANLINER 7,JACKETED qq5 90.NONE ❑ 95.I1NKNOWN .OTHER(S ): Gpy�.e_ U� 093a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3,FILL TUBE SHUT- Ukt 4.TANKMEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT�VE 452. V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER SYSTEM TYPE !.PRESSURE ❑ 2.GRAVITY 460 PRIMARY COMAfNMEM ) STEEL ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 CCR 4J63Ma 3)I 45B ❑ 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 468 ❑ 90.NONE ❑ 95 UNKNOWN ❑ 99.OIHER(SLa'cify): 4Ma SECONDARY CONTAINMENT' 1.STEEL ❑4.FIBERGLASS ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC *lb 90.NONE ❑ 95,UNKNOWN ❑ 99.OTHER(Specify): q PIPINGRURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL 2,DOUBLE WALL ❑ 90.NONE VL VENT,VAPOR RECOVERY 60d (M AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 1 1 0.RIGID PLASTIC 90.NONE 99.0THER(Specify) 46x VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RICH]PLASTIC 90.NONE 99.OTHER(Specify) 4464Lii ? VR PRIMARY CONTAfNMEM ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4Mn e VR SECONDARY CONTARJb6 ❑ 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464a VENT PIPING TRANSITION SUMP TYPE L SINGLE WALL 2.DOUBLE WALL 90.NONE 464h1 RISER PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS to RIGIDPLASTIC 90.NONE 99.OTHER(Specify) 464j RISER SECONDARY CONTAINMENT U I.STEEL U 4.FIBERGLASS 13 10,RIGID PLASTIC90.NONE 99.OTHER(Specify) 4641 4641 FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATEJBOTTOM PROTECTOR 4.CONTAINMENT SUMP 4�a 1 VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ LSIN'GLE WALL ❑ 2.DOUBLE WAI,I, ❑ 3-NOD6PENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4,FIBERGLASS ❑ lO.RIGID PLASTIC 99.OTHER(S 'fy) g6gyc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIALANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 488. Ix APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the ha nsrdous substance stored and that the Information provided herein is true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE d1l. T TITLE APPLICANT NAME(print) 471. APPLICAN UPCF UST-8.1/2 Rev.(122007)