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UNIFIED PROGRAM CONSOLIDATED F UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) TYPE OF ACTION (Check one item only. Form UST permanent closure or removal,complete only this section and Sections 1,if,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 Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4e` I DATE EXISTING UST DISCOVERED: 41o, L FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busims As) 3 AY\ rVeA- BUSINESS SITE ADDRESS I63 IL TANKDESCRIPTION TANK m# 432 TANK MANUFACTURER433 TANK L'ONTIGURAnoN:THIS TANK is 434 c -/0 7�21rX�S LND-AIANETANK 2.ONE ONE MA COMPARTA¢NIFJ)UNT. ae one COM in ureIN DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 tlkx 10 Oao III'TANK USE AND CONTENTS TANK USE 13 Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING [IIc.AV1 nONFUEL4NG 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(leeatle3 Ds Oil) ❑ 5.EMERGENCY GENERATOR FUEL[MC p252815(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(specify): 43% CONTENTS PETROLEUM: ® la REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.LET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLIND FUEL ❑ 9.OTHER PETROLEUM (specify), 44a NON-PETROLEUM:❑ 7.USED OIL ❑ LI ETHANOL El 11.OTHER NON-PETROLEUMS 4496 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SNGLE WALL 2.DOUBLE WAIL 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL ®3.FIBERGLASS 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99,OTHER (S ): 444a SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.3ACRITED 445 ❑ ILA 95.UNKNOWN 99.OTFIBR(S ): 4432 0 ERFIL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT:/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 01.SINGLE-WALLED 2.DOUBLE-WALLED 099,OTHER 460 SYSTEM TYPE ® LPRFSSURE Lj 2.GRAVTIY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFESUCTION CCR 42636(.3) 458 PRIMARY CONTAINMENT 0 1.STEEL Id 4.FIBERGLASS ❑ 8.FLEX®LE ❑ I0.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT L STEEL 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC Nab ❑ 90.NONE •-,95.UNKNOWN ❑ 99.OTHER( PIPINGTURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ W.NONE 4644 VL VENT,VAPOR RECOVERY(VR):AND RISER/FILL PIPE PIPING CONSTRUCTION VENTPRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 17 90.NONE 99.OTHER(Specify) 464 VENT SECONDARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS C110.RICID PLASTIC 90.NONE 99.0 (Spedfy) Oaf VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 199,(.TILER(Seedy) 1�64g VR SECONDARY CONTAINMENT ❑ 1.57EI1. ❑ 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99,OTHER(Specify) 4ab VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 16461 2.DDUBLE WALL 90.NONE 4641 AISER PRIMARY CONTA816ffiNT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 499,OTHER(Specify) 161j RISER SECONDARY CONfALNMENT 1.STEEL 4.FIBERGLASS10.RIGID PLASTIC 90.NONE 99.07HER(Specify) 11 FILL COMPONENTS INSTALLED 1.SPILL BUCKET El 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 451. BL6! VII.UNDER DISPENSER CO!W; NT(UpC) CONSTRUCRON TYPE 1,SNGLE WALL ❑ 2. ALL 3.NO DISPENSERS ❑ 9p,NONE 469aCONSTRUCTIONTERIAL 1.STEELSTIC -Q 99.OTHER(S iy) a696cVIII. CORROSION PTION 'STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.ICURRENT 6.ISOLATION 448.UL. APPLICANT SIRECERTIFICATION:I certify Nat this UST system is compatible with the hazardous stored and Nat the inforvution provided herein Is true,accurate,and Ln full wm Bance with i al reuirements. -f fyAPPLICANT SIGNATURE �2 5-1,lQ DAT - I f O % 47a.APPLICANT NAME(prmQAPPITLE 4n. UPCF UST-B-1/2 Rev.(12/2007)