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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one Tmm per us-T) TYPE OF ACTION (Check me item only. Fora UST permanentsurm cloe nmxwol,complete only Otis swtim and Sections LIT,BI,IV,and IX bel)w) 430 ❑ L NEW PERMIT 3.RENEWAL PER&IIT ❑ CHANGE INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT'CLOSURE ON SITE 5.UST REAL DATE UST PERMANENTLY CLOSED: 430a I DATE EXISTING UST DISCOVERED: 43°6 I. FACILITY INFORMATION FACILITY ID 6(Agency Use Only) _ t BUSINESS NAME(Same as FACILITY NAME or DBA-Doing B33si u As) 3 BUSINESS SITE ADDRESS 103 CITY O� ioA 123 IL TANK DESCRIPTION TANK ID6 432 TANK MANUFACTURER 433 1 TANK CONFIGURATION: THIS TANK IS ❑).ASTAND-ALONE TANK ❑ I •��"-/Y�� ,/^ 2.ONE N ACOMPARTMF.N'1'F.D UNIT.IXAIJ fa wch mtlw wY. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY �OF Z �000 MINTHEUNTT /t437 ,vi © III.TANK USE AND"A NTS TANK USE la.MOTOR VEHICLE PUBLING [I 1b.MARINA FUELING ❑ ic.AVIATION FUELING 439 113.CHEMICAL PRODUCTSTORAGE ❑ 4.HAZARDOUS WASTE OludoUz oip ❑ 5.EMERGENCY GENERATOR FUEL p39c 425281.X.)] ❑ 6.OTHER GENERATORFUEL ❑ 95.UNKNOWN ❑ 99.OTHER(S i : 43% CONTENT'S PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED 440 DIESEL ❑ S.JET FUEL. ❑ 6.AVIATION GAS )] 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S NON-PETROLEUM:❑ 7.USED OIL ❑ METHANOL ❑ 11,OTT"NON-PETROLEUMS i : 44ob IV. TANK CONSTRUCTION TYPE OF TANK L.SINGLE WALL DOUBLE WALL [1 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTE AL G ❑ 95.UNKNOWN ❑ 99.OTHER S i : 694a SECONDARY CONTAINMENT ❑ L STEEL PZ3.FIBERGLASS ❑ 6.EX'T'ERIOR MEMBRANE LINER ❑ 7.JACKETED aAs ❑ 90.NONE 95.UNKNOWN 099.01THER(S ): 44s. OVERFILL PREVENTION I.AUDBa!VISUAL ALARMS 2-BALL FLOAT .FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGIEWALLED LE-WALLED [199.OTHER a60 SYSTEM TYPE .PRESSURE ❑ 2.GRAVH Y ❑ 3,CONVENUONAL SUCTION [14.SAFE SUCTION[23C §26:36(.X3)) 458 PRIMARY CONTAINMENT ❑ 1.MEET, 4.FIBERGLASS I] S.FLEXIBLE ❑ ]0.RIGIN PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.O'I'T1ER(sp-ify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL j2F4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4696 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 469. PIPTNCVR)RBWE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 90.NONE a6w VL VENT,VAPOR RECOVERY(VR)ANEFORSER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL _2'T-FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.MUM(Spe3ify) 464. 469 1 VEIN SECONDARY CONTAAIMENT ❑ I.STEEL BERGLA33 [1 10.RIGID PLASTIC ❑ 90.NONE ❑ 9'9.OTHER(specify) 46e' aw VR PRIMARY CONTAINMENT 0 1.STEEL FIBERGLASS ❑ ]0.RIGID PLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 46984S 464g VR SECONDARY CONTAINMENT ❑ ].STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC 1 ❑ 9D.NONE ❑ 99.OTHER(Spmify) 46N 961 VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL DOUBLE WALL ❑ 90.N071E 4641. RISER PRIMARY CONTAINMENT ❑ T.STEEL ja,4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 RISER SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10,RIGID PLASTIC ❑ 90.NONE ❑ 99.OIHFR(Specify) a6at 464X1 FILL COMPONENTS INSTALLED .SPILL BUCKET ❑ 3.STRIKER PLATF/BO't"TUM PROTECTOR ❑ 4.CONTAINMENT SUMP 451.-. VI.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ L SINGLE WALL .DOUBLE WALL [13.NO DISPENSERS ❑ 90.NONE 46A CONSTRUCTION MATERIAL ❑ 1.STEEL .FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(S 'fy) 4696. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECT'TON .SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION IX. APPLICANT SIGNATURE CERTIFICATION: 1 certify that this UST system is mmpatible with the hazardous substance stared and that the information provided herein is tree,a rade, and in full compliance with Legal requireraestL CANT4IrINATURE DATE 410 APP )CANT 4AME(print) 471- APPLICANT TITLE. �. c 4R. UPCF UST-B-12 L Rev.(12/2607)