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UMMD PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One foam=UST) TYPE OF ACTION (Check one item only. For an UST pmmm=t closure or removal,complete only this motion and Sections 1,11,111,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT [:15.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOS,ID: 4301 DATE EXISTING UST DISCOVERED: 4301 I: FA TION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS 103 Cly 104 IL TANK DISC ON TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK is 434 ❑1.A STAND-ALONE TANK [12.ONE IN A COMPARTMENTED UNIT. complatcom fiorcachmmemmindmudL DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 TANK USE 0011a.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE rmj&dm used On) ❑ 5.EMERGENCY GENERATOR FUEL[HSC i2528t.5(c)) ❑6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 9g. (S ): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED b.PREMIUM UNLEADED 440 ❑3.DIESEL ❑5.JET FUEL ❑6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑9.OTHER PETROLEUM S 440. NON-PETROLEUM:❑ 7.USED OIL METHANOL 11.OTHER NON-PETROLEUMS 440b IV.:-T _ ,`�O1�STRUCTION TYPE OF TANK SINGLE WALL 2.DOUBLE WALL 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL U 3.FIBERGLASS 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING 13 95.UNKNOWN ❑99.OTHER S 444a SECONDARY CONTAINMENT n,1.STEEL 0 3.FIBERGLASS 6. OR MEMBRANE LINER 7.JACKETED 445 ❑ 90.NONE 13 95.UNKNOWN 99. 445a OVERFILL PREVENTION 13 1.AUDIBLE d:VISUAL 2 FLOAT 3.FILL TUBE SHUT-OFF VALVE 452 13 4.TANK M EETSREQUM EMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT PhI��C�r:w P, ` ' �oxs • Qrr ': , PIPING CONSTRUCTION GLE-WALLED 13 2.DOUBLE-WALLED Q 99.OTHER 460 SYSTEM TYPE I.PRESSURE 02. VTl Y 3.CONVENTIONAL SUCTION 04.SAFE SUCTION?3 CCR 2636( 3 438 PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 8.FLEXIBLE 10.RIGID PLASTIC 464 ❑ 90.NONE ❑95.UNKNOWN ❑99.OTHER(S ): 46Ia SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS 8.MEXIBLE 0 10.RIGIDPLASTIC 464, ❑90.NONE ❑95.UNKNOWN ❑99.OTHER(s(Spec*): PIPWRI TURBINE CONTAINMENT SUMP TYPE u 1.SINGLE WALL E3 2.DOUBLE WALL ❑90.NONE 4644 VI.. :' ,�APOR�RECQ ;, (int) ._: 1 _P ,PIPIl'�G�QN�'TBUCTIQ�T, VENT PRIMARY CONTAINMENT El L STEEL U 4.FIBERGLASS E3 10.RIGID PLASTIC U 90.NONE U 99.OTHER(Spaify) 464e 464el VENT SECONDARY CONTAIIdMENT 0 1.STEEL 0 4.FIBERGLASS CI 10.RIGID PLASTIC 13 90.NONE 13 ".OTHER(Specify) 464f 464B VR PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS E3 10.RIGID PLASTIC 13 90.NONE C3 99.OTHER(Specify) 4648 464al VR SECONDARY CONTAINMENT 11 L STEEL 13 4.FIBERGLASS 0 I0.RIGID PLASTIC 13 90.NONE 0 99.OTHER(Specify) 464, VENT PIPING TRANSITION SUMP TYPE 464,1 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 13 90.NONE 0 99.OTHER(Specify) 464) 464'1 RISER SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 13 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464k FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET 3.STRIKER PLATEMOTTOM PROTECTOR 13 4.CONTAINMENT SUMP 4 464k1 64k1 VII.UNYIER'DISPENSER . CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑90.NONE 469a CONSTRUCTION MATERIAL 0 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 99.OTHER 46%.cVIII. CQRROSIQI�L. . . Ql� : : STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) 134.IMPRESSED CURRENT ❑6.ISOLATION 44. IX. CAN'1`SIGN.II , ., CERTIFICATION:D certify that this UST system is compatible witR the hazardous substance stared and that the info herein is frac,accurate, and In full cam with Imalrequirement& APPLICANT SIGNATURE L DATE J r > 4"• APPLICANT NAME(print) �7 l 471. APPLICANT TITLE 4TL UPCF UST-B-I/2 Rev.(12l2007)