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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One foa!per UST) TYPE OF ACTON (Check one item only. Fa'�UST permanent closure or removal,complRe only this section and Sechons I,11,II,1 V,and IX bebw) 430 ❑ 1.NEW PERMIT J7 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION _ 7 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 8.UST VALmm DATE UST PERMANENTLY CLOSED: mw DATE EXISTINGIISTDISCOVEREW L FACILITY INFORMATION FACII.I'Y m a(a8ery UM ony/ ET_-1T__1 - BUSINESS NAME(Same as FACILITY NAME or DEA-DoroB BUS11mes As) l ^ 3 BUSINESS SITE ADDRESS yet) IV3 I CITY IL TANK DESCRIPTION TANK IDa 432 TANK MANUFACTURER 433 TA-MCONPGURATION: THISTANKIS ern- >l 7' ❑I.A STAND-ALONE TANK yF�Z 1 TWQ ONE IN A COMPARTMENTED UNIT. tel' d,✓K�orv,J . ��6 0dc� o� DATE UST SYSTEM IjNSTf+LLED 43s TANK CAPACITY B GALLONS 436 ER OF ARTM�MJS(OTHF /'41A��1llJ� ml .4 r719I .TANK USE AND CONTENTS �6i�,ff LL /^VJ TANK USE MOTOR VEHICLE FUELING 0 It.MARINA FUELING 0 lc.AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE 0 4.HAZARDOUS WASTE(IWd U Od) 0 5.EMERGENCY GENERATOR FUEL JEW 4252813(c)) 0 6.OTHER GENERATOR FUEL 0 95.UNKNOWN 0 99.O HER (Specify): U9a CONTENTS PETROLEUM: 0 Is,REGULAR UNLEADED O le.MIT)GRADE UNLEADED 16.PREMIUM UNLEADED 4m 4r1.7�t IF EL 0 5.JET FUEL 0 6.AVIATION GAS 1.4 S.PETROLEUM BLEND FUEL 0 9.OTHER PETROLEUM S 4001 NON.-PE .0 TUSEDOIL 0 METHANOL I1.01THER NON-PETROLEUMS ' 44a IV. TANK CONSTRUCTION TYPE OF TANK 0 I.SINGLE WALL .DOUBLE WALL 0 95.UNKNOWN 443 PRIMARY CONTAINMENT 0 1.STEEL .FIBERGLASS 0 6.INTERNAL BLADDER Hs 0 7.9IEEL+INIERNALLwNG 0 95.UNKNOWN 0 99 OTHER S 44L SECONDARY CONTAINMENT 0 1.STEEL 0,3.FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER 0 7.JACKETED 445 0 90.NONE 0 95.UNKNOWN 0WOTHER(Spcify4458 OYERpuLPREVENION 634.AUDIBLE&VISUAL ALARMS ):.BALLFLOAT .FILL TIJBESHUf-0FF VALVE 452. 0 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PPNGCONSTRUCTION OLSINGLE-WALLED 494.DOUBLE-WALLED 099.OTHER 4co SYSTEM TYPE .PRESSURE ❑ 2.GRAVITY 0 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION I23OLR SXW(4R3)1 458 PRIMARY CONTAINMENT 0 1.STEEL. 02H.FIBERGLASS 0 &FLEXIBLE 0 10.RIGID PLASTIC 464 0 90.NONE 0 95.UNKNOWN 0 99.MI ER(spadfy): 46sB SECONDARY CONTAINMENT 0 1.STEEL JT.J.FIBERGLASS 0 6.FLEEXIBLE 0 10.RIGIDPLASDC 4646 0 90.NONE 0 95.UNKNOWN 0 99.OIHER(Specify): 464= PPNG/IURBINE CONTAINMENT SUMPTYPE 0 I.SINGLE WALL OhL,2.DOUBLE WALL 0 90.NONE 46w V1.VENT,VAPOR RECOVERY(VR)AN15 RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 I.STEEL PTC FIBERGLASS 0 10.RIGID PLASTIC U 90.NONE 0 99.OTHER(Specify) 464; 454e1 VENT SECONDARY CONTAINMENT 01.STEEL .FIBERGLASS 010.RIGID PLASTIC 090.NONE 099.OTHER(Specify) 46u 4 ft VR PRIMARY CONTAINMENT 0 1.STEEL RF4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 4548 46491 VR SECONDARY CONTAINMENT 0 1.STEEL EA.FIBERGLASS 0 to.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 45ah 45n1 VENT P1PIN67RANSEION SUMP TYPE ❑ 1.SINGLE WALL DOUBLE WALL 0 90.NONE 464i. RISER PRIMARY CONTAINMENT 0 L STEEL FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464i RISER SECONDARY CONTAINMENT 0 L STEEL 2q.FIBERGLASS 10.RIGID PLASTIC 0 9D.NONE WCTHER(Specify) 4641 46Y1 FILL COMPONENTS INSTALLED SPILL BUCKET 0 3.STRIKER PLATEIBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP as14< V IL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 0 1.SINGLE WALL 2.DOUBLE WALL 0 3.NO DISPENSERS 0 90.NONE 46a CONSTRUCTION MATERIAL 0 L STEEL .FIBERGLASS 0 10.RIGID PLASTIC 0 99 OTHER(Specify) 4696c VIIL CORROSION PROTECTION STEEL COMPONENT PROTECITON 2.SACRIFICIAL ANODE(S) 0 4.IMPRESSED CURRENT 0 6.ISOLATION 44s. DL APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hmrstous substance stored and that the information provided herein is true,acrnmte, and to full compliance with 1 reRirementL PLIC GNA s DATE / / 4I0 APPLIC NAME(prim) APPIdCANT IT,LE L, 4n. UPCF UST-13-1/2 Rev.(12/1097)