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05/20/2009 13:53 2094640138 ENVIRONMENTAL HEALTH PAGE 03/04 oc UNIFIED PROGRAM CONSOLIDATED FORM 6 7-f UNDERGROUND STORAGE TANK I J OPERATING PERMIT'APPLICATION-TANK INFORMATION One fp m c us ee TYY E OF ACTION (Cheek one itCm only, AI•an UST Pemumpent closure ormtmvw.complete only this section and Sadians I,II,I11,1V,and IX below) 47n 1.NEW PERMIT 0 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE CJ 7.UST PERMANENT CLOSURE ON SITE E,U5T REMOVAL DATE VST PERMANENTLY CLOSED: 43os DATE EXISTING U$T DISCOVERED: •Tub I. FACILITY R41WORMATION FACILITY ID 9(dgenry Usd Only) - 1 BUS (Same as FACILITY NAME or DBA-Doing Busi"A6) s BUSINE,4 $PTE ADDRFSS IN CITY 161 IL TANK DESCRIPTION TANK1Da 431 IANKbLkNUFA=RER 450 TANK CONFIOLMATTON:THIS TANK IS 434 ASTANO,ALONRTANX ONE OI A COMPARTMBNTHD UNIT. DATE UST SYST ST ED 4v TANKCAPACIT GALLONS 4Jene me h°r"h N°"°a l"O,e unit /970 YNUMBER OF COMPARTMENTS W THE UNIT' do / vas= III.TANK.USE AND CONTENTS TANK USE L.MOTOR VEHICLE PUELJNG Q 16.NARINA FUELING Q Ic.AVIATTONFUELTNG 4,y ❑ J.CHEMICAL PRODUCT STORAGE Q 4.HAZARDOUS WASTE("alud U.1d09) ❑ S.EMERGENCY GENERATOR FUEL[ASC p85T815(c)) ❑S.OTHER GEN ORFUEL Q 93,UNKNOWN Q gg cTNUR( f )1 �� CONTENTS PETROLEIfM: I4.REGULAR UNLEADED Q Ie.MIDGKADE UNLEADED Q 16,PREMIUM UNLEADED 440 3.DIESEL ❑ J,JET FUEL Q 6,AVIATION GAS ❑ B.PBTROLEUMHLEND FUEL ❑9,077•IER PETROLEUM 1 ; �� NON•PETROLEUM,] 7.USED OR Q IO.ETHANOL II.OTHMNON•PETROLEUM $ ci 466 IV, 1'ANKCON3TRUCTTON IYPEOF TANK LSINl1LII WALL Q2 UCTUBLEWALL 0 ELINKNOWN FRIMARYCONTAWMENT LSIEEL ❑ J.FIBERGLASS Q 6,INTgRNA1.BLADDER 41 7.STTJy,+INTERNAL LTNTNG Q 95.UNKNOWN ❑99.OTHER eV 44 SECONDARY COMAMMETTi ❑ I.S71iSL 3.FIBERGLASS Q S.]iXT1iR10R MEMBRANE L1NER ❑ 7,IACKETID �,/ 45 ".NONE ❑95-UNKNOWN ❑W.OTHER 9 I : OVERFILL PRBVF,M70N LAUDIHLERVTSUAL ALARMSU 1..ALLPLOAT J.FILL 7TJ88 SHUT.GFp VALVE A Q4.TANK MP,ETS REQUIREMENTS POR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT 452 V. PRODUCT/WASTEPiPING Co&I PIPING CONSTRUCTION 1.SINGLE•WALLED 1.DOUBLbWALLBD ❑99.OTHFA SYSTEM TYPE I.PRESSURE 1.GRAVITY 3.CONVENTIONAL SUCTION A.SAFE SUCT]tMl f3 CCR 6J s 3 44ax PRIMARY COMA]NMENT T.STEEL Q 4.FIBERGLA93 B.FLEXIBLE ❑ 10.RIGID PLASTIC 464 90.NONE ❑ 9s.UNKNOWN Q 99.0THER clb); K4p SECONDARY CONTAINMENT I.STEEL I.FIBERGLASS ❑d.FLEXIBLE ❑ 10.AIGIA PLASTIC V,14 ❑ 90.NONE 95.UNKNOWN ❑ 99,OTHER S scl : 4Mc PIPMG?URHiNE COMNNML+NT SI/A4P TYPE ❑ 1.SINGLE WALL 1.DOUBLE WALL 90.NONE 4Wd VI,VENT,VAPO RICOVRRY{VR)ANDRISER,/FILLPxEE INGCONSTRUCTION VENT PRIMARY CONTAINMENT I.STEEL 4.PIBERGLASS IO.RIGfO 9LASTIC `O.NONB 99.pTFTgR($peel%) 4641 VENT SECONDARY CONTAINMENT Q 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99,OTHER(gpc41Q,) - 444e1t VR PRIMARY CONTAINMENT Q1,MEL Q4.FIBERGLASS 010.RIGID PLASTIC N Own Q 90.NONE 99,OTHER(Spxify) 4646 VRSECONOARYCONTArNMEM Q LMEL Q 4.FIBERGLASS Q 10.AIGIDPLASTICN 4 I ❑90.NONE 0 99.OT,[ER(3perify) 464, VENT PIPING TRANSITION SUhfPTYPE I.STLE WALC 2DOUBLE WALL 90.NONE �✓ 46461 ATSE0.PTUMAXAIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS .10,IUOM PLASTIC 90.NONE99.OTHER(Specify) 44qL RISER SECONDARY COMAINM6IYT 1•STEEL 4.17HEROLA55 10.RIGID PLASTIC 90.NGN5 99.G7PIeA 4 I FILL COMPONENTS INSTALLED (spenry) k I.SI'[LL BUCKET 3.3TR1XER PLATEIROTTOM PROTECTOR 4.CONTAINMENT$UMP46 1 VII.UNDER DISPENSER CONTAINMENT(I)DG) 4511` CONSTRUCTION TYPF: ❑ I.SINGLE WALL Q1.DOUELEWALI, Q 3.NO 015 EKE 90.NONE 469p V; CONSTRUC170N MATERIAL ❑ LSTEIp. ❑ 4.FIBERGLASS Q 10.RTCID PLASTIC ❑ 99.OTHEA al VITT. CORROSIONPROTECTIOIJ k96e STEEL COMPONENT PROTECTION ❑ 2.SACRff[gAL ANODE(S7 ❑4.IMPR63SED CURRENT 6.ISOLATTON 4s. IX. APPLICANT SIGNATURE CERTIFICATION:I certify 11"this UST PPshI le r timbl6 wllh the hazRrdoaa anbapnec stored and that the Information provided herein la tree,aecoratel and In R40 tom Iinnce with I 1 r dremente. APRUCANTSIGNATURE - DATE APPLICANT NAME(print) 471. APPLICANT TITLE .2o -- 972. UPCF UST-B-1/1 Rev.(I7JZ007)