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r 430 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 pemlanent closure or removal,complete only this section and Sections I,11,!B,IV,and IX below) ❑ 1.NEW PERMIT [13.RENEWAL PERMIT 19 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 171 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) O G 2?-7 , _ _ 1 BUSINESS NAME(Same as FACILITY NAME m DBA Business As) 3 BUSINES ? SS ZL Im lY crry �li/JP lif. 04 IL TANK DESCRIPTION TANK ID# Q�`i5`�-p'i 432 TANK MAN[JFA JJRREERR 433 .rTrA1}NK CONFIGURATION: THIS TANK IS 434 ��6 T�fel /l/ ` a-52.O STAND-ALONE TANK UNII D S SYSTEM INSTAL D us [/ LJ mewl L E TANK CAPACfl.Y IN GALLONS 436 NUMBER OF COMPARnGENERATOR 43'1 ell III.TAMC USE AND CONTENTS TANK USE Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AV439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(Incu4c Uses l ❑ 5.EMEATOR FUEL[HSC§25281.5(9)] ❑ 6.OTHER GENERATO UEL ❑ 95.UNKNOWN ❑ 99.OT43% CONTENTS PETROLEUM: Ia.REGULAR UNLEADED ❑ Ie.MIDGRADEUNLEADED ❑ IbPREHD❑ 3.DIESEL ❑ 5.LET FUEL ❑ 6.AVI❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S440. NON-PETROLEUM:❑ 7.USED OI. ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS . 4406 IV. TANKCONSTRUCTION _ TYPE OF TANK 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN qq3 PRIMARY CONTAINMENT ®'f.STEEI, ❑ 3.FIBERGLASS 6.INTERNAL BLADDER qq4 ❑ 7.STEEL I INTERNAL L G ❑ 95.UNKNOWN ❑ 99.OTHER S a44a SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.1pCKE1'ED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S ): 445a OVERFILL PREVENTION 1.AUDIBLE It VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452 ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCDOWASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L GLE-WALLED . UBLE-WALI.ED ❑99.OTHER 46p SYSTEM TYPE I.PRESSURE 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION Ek§2636(aA3) 458 PRIMARY CONTAINMENT ❑ 1.STEEL G34.FIBERGLASS ❑ S.FLEMBLE ❑ 10.RIGm PLASTIC 469 ❑ 90.NONE ❑ 95.UNKNOWN '] 99 99.OTHER(Specify): 46y SECONDARY CONTAINMENT ❑ 1.STEEL .FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGH)PLASTIC 4646 ❑ 90.NONE ❑ .UNKNOWN ❑ 99.OTHER(Spedfy): 4649 PIPMG)TURBINE CONTAINMENT SUMP TYPE I.SMCLE WALL ❑ 2.DOUBLE WALL 090.NONE 4694 VI VENT,VAPOR RECOVER (VR)AND RISER/FELL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENf I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC U 90.NONE 99.OTHER(Specify) 469e VENT SECONDARY CONIAINMENf 46411 1.S EL 4.FIBERGLASS ❑ 10.RIGID W NE 99.OTHER(Specify)VR PRAMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGm PLANE 99.OTHER(Specify) 964gVR SECONDARY CONTAINrAENT 1STEEL 4.FIBERGLASS ❑ 10.RIGm PLANE 99.OTHER(Specify) 4646VENT PIPING TRANSITIONSUMP TYPE CLE WALL 2NE 464i.RISER PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGD)PLANE 99.OTHER(Specify) 4641 RISER SECONDARY CONCAINMENT 1TEEL 4FIBEC10.RIGID PLAE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET .STRIKER PLATE/BOTTOM PROImiUK .CONTAINMENT SUMP 451. UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE 1. GLE WALL ❑ 2.DOUBLE WALL LI 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL .STEEL ❑ 4.FIBERGLASS D 10.RIGID PLASTIC ❑ 99.OTHER(S 'fy) 46969 VIII. CORROSION PROTECTION STEEL COMPONENC PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT M16.ISOLATION 448. IX APPLICANT SIGNATURE CERTIFICATION:I certify that thio UST system is compatible with the hazardous substance stored and that the information provided herein Is true,ucurate, mu§fu full rom nee with legal requirements. APPLIC ATU DATE 6 Ow. APPL ANT NAME(prim[ .l 4n. UPCF UST-B-1/2 I", Rev.(12/2007)