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t oe 'm UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per us TYPE OF ACTON (Cheat one Dem o my For o(LST closwe w rr�novo(.complex only our section and Seccia"1..A!I!.If:and LY below) 4 [3 I NEW PERMIT L[3 RENEWAL PFRMIT [3 S.CHANGE OF INFORMATION 6 TEM4pRAAY USS CLOSURE T.11ST PEFdIANENTCLASURE ON SITE S.UST REMOVAL DATE UST PERMANEMT.Y CLOSED: ' DA1E E)USTALO UST DISCOVERED: L FACILITY INFORMATION FACB,ITY m h(Agency Use Only) BI)STNESS NAME(Same as Facility Nave w DB1A Doing Bmiew3 Aa) i BUSINESS SITE ADDRESS1 103. BUSINESS SERE CMY 1 . gt7�5 � ✓ �tt,v� �icnpVt Q61. Iht01AF'/el It cy IL TANK DVACREMON TANK ID 0 432 TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434, p 1 &q.A STAND-ALONE TANK cagnYr �sh Ptutl 2.ONE INA COMPARTMOfIED LNJT 1, Eft DATE UST SYSTEM INSTALLED 4M. TANK CAPACITY IN GALLONS 43S NUMBER OF COMPARTMENTS IN THE UNIT 437• M. TANK US$AND CONTENTS TANK USE 1 MOTOR VEHICLE FUELING E3Ib.MARINA FUELING Q Ic.AVIATION FUELING ' 39. . ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Ie.bels Ilse!OfO Q S.EMERGENCYGEWRAT(MFUEL(H4CIIJMf.sNlf ❑6.OTHER GENERATOR FUEL ❑ 93.UNKNOWN ❑ 99.OTHER ): CONTENTS PETROLEUM: Rr 1.REGULAR UNLEADED ❑ la MIDORADE UNLEADED ❑ Ib.PREMIUM UNLEADED 44D. ❑ 3.DIESEL ❑ 5.JET FUEL [] 6.AVIATION GAS 410s ❑ 6.PETROLEUM BLEND FUEL Q 9.OTIaE0.PETROLEUM(SpeAM: NON-FEMLEUNL 7.USED OR. 10.ETFUNOL II.01HERNON-PETROLEUMS _ IV: TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL_jr.DOUBLE WALL ❑ 95.UNKNOWN . .. PRIMARY CONTAINMENT ❑ I.STEEL IN 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 4w Q 7.STEEL-!NEERN LINING ❑ 95UNKNOWN 13 99.OTHER(See ia): _._.._..... . SECONDARY CONTAINMENT' ❑ 1.97EEL .FMEROLASS Q 6.EXTERIOR MEMBRANE LINER D 7.JACKETED 445L 90.NONE Ij 95.UNKNOWN ❑99.OTHER(s ): ...-----. .. pVgppBy,PREVEHTKB{ Q \.AIIDIBIEtYL4llAL A1.ABAL4 Q 2-BALLFT.OAT ❑3.FILL TUBE SHUT-OFF VALVE 4.TANK MEETS UIIEMENLS FOR EXEMPTION FROM OVERFILL PREVENTION MUIPMENT V, PRODiJa/WASTE PIPING CONSTRUCTION PIDWO CONSTRUCTION... ).SINGLE WALL Er2.DOUBLE WALL W_99 OTHER SYSTEM TYPE 4;�I.PRESSURE p�.eJ �2.GRAVITY ❑3.CONVENITONALSUCTON .SAFESUCTIONry CCR12eM(sNBI 451. MVAAR'(CO!f1PdNy&J4'T ❑ 1.5TE43. 4.fQE3lGLASB ❑S.FIExIBIc Q 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER( ): 464L SECONDARY CONTAINMENT ❑ 1.STEEL ❑4.FIBERGLASS Q &FLEXIBLE ❑ 10.RIOID PLASTIC 4No Q 9o.NONE Q 9s.UNKNOWN a 99 OTNBR(9Pm69'). 4e4e P�ING/TURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 4W V , 31 ,:R�A"UCOV Y(VR)'ARID RISER/'FUAj PWK PIPING�fl�[b" -,_VCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL B 4.FIBERGLASS Q 10.Rbm PLASTIC 1390-NONE Q 99.OTHER(speeih): VENT SECC9ID.ARYCTAK!'AINAFENT D 1.STEEL a4.FIBERGLASS _Q Io.RIGID PLASTIC C390.NONE ❑ 99.mtmR(Spec*): VR PRIMARY CONTAINMENT [31.STEEL W4.PMEROIASS ❑ 10.RIGID PLASTIC ❑ 90.HONE ❑ 99.OTHER(SpeciQ7: VRSECGNDARY CONTAENEMT Q 1.STEEL 4.F®EROLASS ❑ I0.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(SPmlb'): L VENC PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL Ia•2_DOUBLE WALL ❑ 90.NONE _ RISER PRBdARY CONT4.FIBERGLASS 0 10.RIOm PLASTIC ❑ 90.NONE ❑ 99.OTHER(simc*): 464 RISER SECONDARY CONTAINMENT ❑ 1.STEEL EF4,FIBERGLASS ❑ lo.muw PLASTIC ❑ 90.NONE ❑ 99.OTHER(SPwib•): 46411. FII.COMPONENS INSTALLED Q 1.SPILL BUCKET 6j 3.STRIKER PLATE/BOTTOM PROTECTOR 4.CONTAINMENT SUMP K VII. UNMR DISPENSER CONTAINMM CONSTRUCTION TYPE I_smGLE WALL �'2.DOUBLE.WALL ❑ 3.NO DISPENSERS Lj 90.NONE CONSTRUCTION MATERIAL __-❑ 1.STEEL 12.4.FIBERGLASS Q 10.MO PLASTIC 0 99.OTNER(Specify) Wk VIII CORROSION PROTECTION STEEL COMPONENT PROTECTION Q 2.SACRIFICIAL ANODES) U 4.IMPRESSED CURRENT ❑ 6.ISOLATION DL APPLICANT SIGNATURE CERTIFICATION: 1 certify, Hut this UST system is eooWtible with the itssardoos emmo'"e atoeed and Khat the laformNoe prv4klod beeeio b+n" Seem in captlame.with Iftal regalremem4 ite. APPLICANTS%MIAhluRE I DATE C" / D sn. APPLICANT NAME(print) 471.` l APPLICANTTITLE UPCF UST-B Rev.(I L2007)-1/2 www.mmYoes.otg EfFeedve OYI7068