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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form Per UST) TYPE OF ACTION (Check one item only. For an UST penetrant closure or temcvul,complete only this section and Sections L II,III,IV,and IX below) 439 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4104 1 DATE EXISTING UST DISCOVERED: ° I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) L J T 1 G BUSINESS SITE ADDRESS Im CITY IN Z W• N4i3 e. WG 4C IN IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK Co,,,,U AnON:THIS TANK is 434 ®1.ASTANo-AIANETAW 3 76 07 466 Xe Kx e5 [12.ONE IN A COMPARTMENTED UNIT. // Convlgc.ncemef6rocb. inngum, DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 434 NUMBER OF COMPARTMENTS IN THE UNIT 437 i 9 6 as 2 III.TANK USE AND CONTENTS TANK USE 59 Is MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ la AVIATION FUELING 439 13 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(haiude+U4ed Oil ❑ 5.EMERGENCY GENERATOR FUEL[HSC 125281.3(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ❑ la-REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ® Ib.PREMMMUNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440c NON-PETROLEUM:0 7.USED OIL ❑ 10.ETHANOL 11.OTHER NON-PETROLEUMS 449b IV TANK.CONSTRUCTION TYPE OF TANK 0 I.SINGLE WALL 0 2.DOUBLE WALL 095.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL M 3.FIBERGLASS 0 6.INTERNAL BLADDER 4N ❑ 7.STEEL+INTERNAL LINMG ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL IN 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ T JACKETED 45 90.NONE )5.UNKNOWN 0 99.OTHER S ): 443s OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 432. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT WASTE PIPING CONSTRUCTION PIING CONSTRUCTION ❑1.SINGLE-WALLED M 2.DOUBLE-WALLED 0 99.OTHER 460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 23 111 636(aX)) a5a PRIMARY CONTAINMENT - 1.STEEL R 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIG.PLASTIC 464 ❑ 90.NONE 0 95.UNKNOWN ❑ 99.0THER(Specify): 464 SECONDARY CONTAINMENT 1.STEEL Eg 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIG.PLASTIC 46ab 090.NONE _ 95.UNKNOWN 099.OTHER(Specify): 464c PIPING?UTIBINE CONTAINMENT SUMP TYPE I.SINGLE WALL 2.DOUBLE WALL [3 90.NONE 46x4 VI.VENT,VAPOR RECOVERY(VR):AND RISER/FILL.PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT a 1.STEEL 4.FIBERGLASS 11 10.RIG.PLASTIC 90.NONE f 99.OTHER(Specify) 464 461e1 VENT SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS El 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Spcify) 46/f 4MFl VR PRIMARY CONTAINMENT 0 1.STEEL G 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 199.OTHER(Specify) 464g 464 I VR SECONDARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Spaeify) /b4h 46N1 VENT PIPING TRANSITION SUMP TYPE LSMGLE WALL M 2.DOUBLE WALL 90.NONE 464i. RISER PRIMARY CONTAINMENT CRK L STEEL U 4.FIBERGLASS U 10.RUG.PLASTIC UR 90.NONE L 1 99.OTHER(Specify) 4Mj 464'1 RISER SECONDARY CONTAINMENT 52 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464k 6 FILL COMPONENTS INSTALLED al.SPYLLBUCKET 0 3.STRIKER PLATFIBOTTOM PROTECTOR El 4.CONTAINMENT SUMP ry+31.a-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 15 L SINGLE WALL 0 2.DOUBLE WALL 0 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL 1g I.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC a .99.OTHER(S Ify) a69bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT 49 6.ISOLATION we. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system it compatible with the hazardous substance stored and that the Information Provided herein is true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE S DATE !Z/(7D�G4N. APPLICANT NAME(prin[) Sully urmfpky' SI/"�H 471. APPLICANT TICILE OWA Ii�^IZ aP. UPCF UST-B-1/2 Rev.(122007)