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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (OM form PQ usT) TYPE OF ACTION (Check one item only. For a UST closure or removal.complete only this section and Sections I.I.ITL IV.m d I X below) 430. 1.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: DATE EXISTING UST DISCOVERED: 430h L FACILITY INFORMATION 1. FACILITY ID#(Agency Use Only) - - BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) .Qin /-/-z -Tu-swas SITE ADDRESS 103. BUSINESS SITE CITY 104' 7/3 4/ c1 leo IL TANK DESCRIPTION TANK ID# 432. TANK MANUFAC'T'URER 433. TANK CONFIGURATION:THIS TANK IS 434• ❑ STAND-ALONE TANK c mat for �'2 ONE[N A COMPARTMENTED UNIT pace mro mit.dc DATE ST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436• NUMBER OF COMPARTMENTS IN THE UNIT 437. 0_3 e.z9.a 1 III. TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ le.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(brLde Used 011) ❑ 5.EMERGENCY GENERATOR FUEL(TSC#252813(0) ❑ 6.OTHER GENERATOR FUEL ❑95.UNKNOWN ❑99.OTHER(Specify): 439s. CONTENTS PETROLEUM: JK 1.REGULAR UNLEADED ❑ ic.MIDGRADE UNLEADED Cl Ib.PREMIUM UNLEADED 440. ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 139.OTHER PETROLEUM(Specify): 4401 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S ): 440h IV. TANK CONSTRUCTION TYPE OF TANK 1.SINGLE WALL DOUBLE WALL ❑ 95.UNKNOWN 443. PRIMARY CONTAINMENT ❑ 1.STEEL $FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ❑95.UNKNOWN ❑99.OTHER(Specify): _444x•_. SECONDARY CONTAINMENT ❑ 1.STEEL No3.FIBERGLASS p 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99-OTHER(Specify): 4452. OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-0FF VALVE 45' 4.TANK MEETS RE FOR EXEMPTION FROM OVERFILL PREVENTION EQUIP V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I.SINGLE WALL DOUBLE WALL ❑ 99.OTHER 460' SYSTEM TYPE [J-'1.PRESSURE ❑ GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION C23 CCR§2636(-01 458. PRIMARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ l0.RIGIDPLASTIC 464• ❑ 90.NONE ❑ 5.UNKNOWN p 99-OTHER( ): 46/a SECONDARY CONTAINMENT ❑ 1.ST4.FIBERGLASS ❑ 8.FLEXIBLE EEL ❑ 10.RIGIDPLASTIC 464h ❑ 90.NONE ❑95.UNKNOWN ❑ 99.OTHER(S ): 464c PIPINGfMRBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL a 2.DOUBLE WALL 0 90.NONE 4644 VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL 1g.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464el. VENT SECONDARY CONTAINMENT p 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 fl• VR PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ l0.RIGID PLASTIC O 90.NONE ❑ 99.OTHER(Specify): 464464 f. VR SECONDARY CONTAINMENT p 1.STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC El90.NONE 1399.OTHER(Specify): 46h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE RISER PRIMARY CONTAINMENT 04 STEEL ❑4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑99.OTHER(Specify): 466•+• RISER SECONDARY CONTAINMENT p 1.STEEL E34.FIBERGLASS ❑ 10.RIGID PLASTIC p 90.NONE ❑99.OTHER(Specify): 46411• FILL COMPONENTS INSTALLED 02.SPILL BUCKS[ JgLjk STRIKER PLATFlBO't mm PROTECTOR 4.CONTAINMENT SUMP q3i&c VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ 99.OTHER(Specify) VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I cerdy that this UST system h compatible with the hazardous sabstan¢e stored and that the lubrmation pruned herein is true, accurzte,and in1veo withbwmairemeats 470. APPLICANT SIGNATURE DATE A APPLICANT NAME(Prim) 471. APPLICANT TITLE 472. ) Dw �A-- UPCF UST-11 Rev.(12/2007)-1/2 www.anidocs.org Ef eetive OV17/08