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It I 1. .s 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 permanent closwe or removal, complete only thissection and Sections I, II, BI, IV, and IX below) 430 ❑ L NEW PERMIT ® 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 43081 DATE EXISTING UST DISCOVERED: /d 4306 I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) _ I 3 BUSINESS NAME (Same as FACILITY NAMEeor DBA -Doing Business AAs) e� 1 CC�3cA �SfO�! O I♦ie A! >kfe/?ir{t ySlrflSflGi .r EX/(I✓/ IIQ��A!/FN/� BUSINESS SITE ADDRESS 1°3 CITY 1 IL TANK DESCRIPTION TANK ID# 433 TANK MANUFACTURER 433 TANK CONFIGURATION: TIBSTANKIS 434 A STAND-ALONE TANK 2. ONE M A COMPARTMENTED UNIT. LCA hoaw A Irl/✓h Complete one pass for wch com amnent in the wit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 /w p�• .Ge//i III. TANK USE AND CONTENTS TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ In.AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ',n.4. HAZARDOUS WASTE(I.clude Uned Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §2529L5(c)I O 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439. CONTENTS PETROLEUM: ❑ In. REGULAR UNLEADED ❑ In. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED "a ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ e. PETROLEUM BLEND FUEL 14 9. OTHER PETROLEUM (Specify): 4 /9//V p ( L 440a NON -PETROLEUM: K 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1. STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (S i ): 414. SECONDARY CONTAINMENT ❑ I. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN 1199. OTHER (specify) 445. OVERFILL PREVENTION 0 I. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I. SINGLE -WALLED ❑2. DOUBLE -WALLED [199. OTHER 460 SYSTEM TYPE ❑ 1. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION IM CCR §2636(.X313 458 PRIMARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(S ify): 464a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 4646 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPNGn URBNE CONTAINMENT SUMP TYPE ❑ I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 4Md VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT ❑ L STEEL L1 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ ].STEEL ❑ 4. FIBERGLASS 0 ILRIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464f 464H VR PRIMARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE D W. OTHER (Specify) 464g 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL D 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ W. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL 0 2. DOUBLE WALL D 90. NONE 4Mi. RISER PRIMARY CONTAINMENT ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641 464' 1 RISER SECONDARY CONTAINMENT (IL STEEL [14. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE ❑ 99.OTHER (Specify) 464k 464kl FILL COMPONENTS INSTALLED ❑ 1. SPILL BUCKET ❑ 3. STRIKER PLATEBOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 451a -c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ I. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION ug. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full compBance with legal requirements. APPLICANT SIGNATURE I DATE 4J(1 Ole APPLICANTNAME(pr' ) 471' APPLICANTTITLE 472. A, JR e - A t • 7 UPCF UST -B - 112 Rev. (1212007)