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• • II w IED PROGRACONSOLIDA UNIFIED M TED FORM O UNDERGROUND STORAGE TANK % / /C-) ►`` PERATING PERMIT APPLICATION-TANK INFORMATION (one form TYPE OF ACTION (Check one item only. Fora USP closure or removal.comp(ele only this section and Sections I,/!,//I.!{;aM/Xbe(owJ US'o, 1.NEW PERMIT ❑ 3.RENEWAL PERMIT 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ONSITE El5.CHANGE OF INFORMATION DATE UST PERMANENTLY CLOSED: 4J0n S.UST REMOVAL DATE EXISTING UST DISCOVERED: Y-�/S �C 430b. FACILITY ID#(Agency Use Only) I. FACILITY INFORMATION BUSINESS E(Same as Faci/i Name or DBA-Doing Business As) O 1 BUSB`�GS SRE ADDRESS llwvv/c' 3 6 103. CITY TANK ID# 432. IL TANK DESCRIPTION TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434 ��shry�.F 45W� 4� � I.A STAND-ALONE TANK Complete ow p ga fm a h DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS ' 436. Q 2.ONE IN A COMPARTMENTED UNIT compahnm,in me mic NUMBER OF COMPARTMENTS IN THE UNIT 437. M. TANK USE AND CONTENTS TANK USE Q la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING may.CHEMICAL PRODUCT STORAGE ❑ 4.riAZARDOUS WASTE(rich Usm qi Q lc.AVIATION FUELING 439. ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ) Q S.EMERGENCY GENERATOR FUEL(HSC 025281.5(c)] CONTENTS PETROLEUM; ❑ la.REGULAR UNLEADED --- OTHER(S�fg)' 4311. ❑ 3.DIESEL Q Ic.MIDGRUNLEADED ❑ Ib.PREMIUM UNLEADED 440, ❑ 8.PETROLEUM BLEND FUEL Q S.JET L FUEL f-I 6.AVIATION GAS 9.OTHER PETROLEUM($pacify): NON-PETROLEUM;Q 7.USED . Q 10. 011.OTHERNON-PETROLEUM(S eci ): 4406. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL PRIMARY CONTAINMENT ❑95.UNKNOWN X01.STEEL LJ A FIBERGLASSQ 6.IN BLADDER 441. ❑ 7.STEEL+IN'fERNALLINING ❑ 95.UNKNOWN ' SECONDARY CONTAINMENT1.STEEL ❑7,FIBERGLASS Q OTHER(Specify): 444a ❑ 90.NONE Q 9 EXTERIOR MEMBRANE LINER Q 7.JACKETED - H5. ❑95.UNKNOWN Q 99.DTriEA($ ..- OVERFILLPREVENTION ❑ I.AUDIBLE&VISUAL ALARMS --��) 445. ❑4.TANK MEETS RE UIREMEMSF�EXEaIPfiON FROM OVERFIO PREVENT ON EHUIPMEM�VE 452 V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION L SINGLE WALL ❑ 2.DOUBLE WALL SYSTEM TYPE $I.PRESSURE Q 2 ORAVp1Y Q 99 OTHER 460 PRIMARY CONTAINMENT ] STEEL ❑3.CONVENTIONAL SUCTION -Q q,gAFE SUCTION[23 CCR 1'-636(sX3)] 458. ❑4.FIBERGLASS a^S,FLEXIBLE ❑ 10.RIGID PLASTIC 464. ❑ 90.NONE ❑ 95.UNKNOWN 9q,OTHER(Specify): SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS 464a ❑ 90.NONE ❑8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646. PIPING/TURBINE CONTAINMENT SUMP TYPE Q95.UNKNOWN x'99.OTHER(Specify) yl.0 .ft;, q (&- 4W ❑ 1.SINGLE WALL ❑2.DOUBLE WALL 90. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION 464a VENT PRIMARY CONTAINMENT ❑ 1.STEEL Q 4.FIBERGLASS PENT SECONDARY CONTAINMENT ❑ 80.RIGID PLASTIC [,1 90 NONE Q 99 OTHER(Spxify): 4 ❑ 1.STEEL Q 4.FIBERGLASS ❑ L0.RIGID PLASTIC 90.NONE 4Ma1. VR PRIMARY CON'TAINMEN'T ❑ 1.STEEL Q 99.OTHER(Specify); 464n. ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC IN g0.NONE Q 99.OTHER(Spwify): VR SECONDARY CONTAINMENT 4N s ❑ 1.STEEL ❑4.FffiERGLASS Q 10.RIGID PLASTIC Q 99.OTHERS 4641, VENT PIPING TRANSITION SUMP TYPE SI g0.NONE ( pacify): 4Mh1 ❑ 1.SINGLE WALL ❑2.DOUBLE WALL 19 90.NONE 4 RISER PRIMARY CONTAINMENT ❑ 1.STEEL Q 4.FIBERGLASS Q 10.RIGIDPLASTR'. 90.NONE Q 99.OTHER(Spwify): 4643. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 4641. FILL COMPONENTS INSTALLED ❑ I0.RIGID PLASTIC 90.NONE Q 99.OTHER(Specify): 4644. ❑ 1.SPILL BUCKET Q 3.STRIKER PLATFIBOTTOM PROTECTOR 4Mt1. VII. UNDER DISPENSER CONT Q 4.COMAINMEM SUMP 45Ia CONSTRUCT]— ❑ LSINGLEWALL AINMENT(I7DC) CONSTRUCTION MATERIAL Q 2 DOUBLE WALL Q 3 NO DISPENSERS 90.NONE 469. ❑ 1.STEEL Q 4.FIBERGLASS Q t0.RIGID PLASTIC ❑99.OTHER(Specify) 4696 VI L CORROSION PROTECTION 469` STEEL COMPONENT PROTECTION Q .. SACRIFlCIALANODE Si ( Q 4.IMPRESSED CURRENT 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system Is compatlh@ wNh the►ayardo accunte with IEal oireasumm, aa aobstaeee scored and that the Information provided herein V true, sad is fuB com Beoee APPLICANT SIGNATURE DATE 4'10. APPLICANT NAME(print) a71. APPLICANT TITLE an. UPCF UST-B Rev.(12/2007)-1/2 www.nidoes.org