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UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK /o Z <br />OPERATING PWATr APPLICATION - TANK INFORMATION one: foam p., rases <br />TYPE OF ACTION (Chockone itam oady. For UST past euro oranowajL campL-m sally Ebb aeetloa and seedm IL It, IT IV. and IX blow) <br />❑ 1. NEW PERMQT 3. RENEWAL PERMIT © S. CHANGE OF tNFORMATIOIN <br />6. TEMPORARY UST CLOSURE 7. USI PERMANENT CLOSURE ON SITE Q 8. UST REMOVAL <br />DATE UST PERMANENTLY CLOSED: 4 1 DATE EXISTING UST DISCOVERED: <br />L FACILn Y IIYFORMATION <br />4" <br />446 <br />FACMY ID N (AgeM Um Omfy) <br />445 <br />44M <br />OYBRFgL MtEYEMI0IN AUDIBLE A VISUAL ALARMS 2. BALL FLOAT jZk3. FULL TUBE SHUT -017 VALVE <br />4. TANK MEETS UBEiMEM FOR B UMFIION FROM OVHRFH.L PREVENTION WNWNT <br />L <br />V. PRODUCT I WAM PakmG 4"IJN$TRUCTION <br />PIPING CONSTRUCTION L SINGLE WALLED Ul DOUBLE -WALLED El 99 OTHER <br />460 <br />SYSTEM TYPE 1. PRESSURE GRAVITY 3. CONVENTIONAL SUCTION 4. SAFE SUCTION a3t a <br />I <br />BUSlNSSS NAME (Som u FACILITY NAME ord <br />E 7to�e�c� uv d Mo"DA�rg� <br />464b <br />4&k <br />BusADDRESS <br />N • L l �olC,.cav-1 <br />CITY <br />106 <br />IL TANK DESCRIMON <br />VENT PRIMARY CONTAINMENT U 1. STEEL M4.FMEROl.ASS Ll I&RXHDFIJ43= E3 90. NONE U 99.017HER (Sperm <br />TANK B? A ,T b/ l <br />TANK MANUFACTURER433TAI& <br />COMOURATIoN: THIS TANK IS <br />64 <br />U�CnS �ilfJl��f� <br />ff 1. A STANIYAI.,OM TANK <br />2.ONfiINACOMPARTMBNTEDUNrr. <br />J <br />6rdkb dwil* <br />DATE US�,SY,B SEM INSTALLED <br />TANK ACUITY IN GALLONS <br />F compINTHEUNIT <br />417 <br />III. TANK USS AND CONTEM <br />TANK USEIm MOTOR VEHICLE PURIM Cl Ib. MARINA FURt3NO © 1c. AVIATION FUELING <br />I3. <br />CHEWICAL FRODUCC STORAGE ❑ 4. HAZARDOUS WASTE lledaan VM ORD 17 S. HMMK 11 WY G04HRATOR P.BL (nw HM2te.a(e)j <br />6 OTHER OENBRATOR FUEL Q 93. UNKNOWN Q ".OTHER ftecift <br />439E <br />CONTENTS PmoLEUM: a. ANGULAR UNLEADED D la. MIDaRADE UNLEADED 0 lb. PREMIUM UNLEADED <br />440 <br />❑ 3. DIESEL 0 S. JET Fm 0 6. AVIATION OAS <br />0 B. PETROLEUM BLEND FUEL Q 9. OTHER PETROLEUM <br />440a <br />NON -PETROLEUM: 13 7. USED OIL E3 L0. ETHANOL <br />TI It rrrtmx DlD19Al_1lRTRnf JlI Md lRw -M%- <br />440Q <br />PRIMARY CONTAINMENT U I. STEEL (W3. FIBERGLASS El 6. DOWMAL BLADDER. <br />7. STEL } INTERNAL LINING 93. UNKNOWN 13 MOTHER, <br />4" <br />446 <br />SRCONDARY CONTAINMENT 1. STEEL6. MITERIOR MEMBRANE I2QR 7. JACKETED <br />90. NONE 9 93. UNKNOWN 1299.0THast LSEM <br />445 <br />44M <br />OYBRFgL MtEYEMI0IN AUDIBLE A VISUAL ALARMS 2. BALL FLOAT jZk3. FULL TUBE SHUT -017 VALVE <br />4. TANK MEETS UBEiMEM FOR B UMFIION FROM OVHRFH.L PREVENTION WNWNT <br />L <br />V. PRODUCT I WAM PakmG 4"IJN$TRUCTION <br />PIPING CONSTRUCTION L SINGLE WALLED Ul DOUBLE -WALLED El 99 OTHER <br />460 <br />SYSTEM TYPE 1. PRESSURE GRAVITY 3. CONVENTIONAL SUCTION 4. SAFE SUCTION a3t a <br />43H <br />ff"FIBERCILASS <br />PRIMARY CONCAII IT 1. STEEL 9 FLBRBLE 10. ROOM PL,ASTHC13 90.NONE . UNKNOWN 09946411 <br />SECONDARY CONTAINMENT 13 I. STEEL FIBERGLASS 8. FIDOIBLB tj 10. RWID PLASTIC <br />90. NONE O 93. UNKNOWN 99.OT BR <br />464b <br />4&k <br />PIPINGnURHINE CONTAIN MINT SUMP TYPE 1. SINGGLII WA�LLL 2. D01B.S MALL 90. NONE <br />air <br />a� <br />VL_VINTr VAPOR.RLCOY 17 RIf IqD PIM� FUJ.. I rBWiG CQ U(. Old <br />VENT PRIMARY CONTAINMENT U 1. STEEL M4.FMEROl.ASS Ll I&RXHDFIJ43= E3 90. NONE U 99.017HER (Sperm <br />4= <br />45181 <br />VENT SECONDARY CONrADMUM 0 I. STBBL W47FIBEROLASS In 11 RIGID ELASTICIW 91L NONE 99 UrNM (SBGCUVI <br />464r <br />IF 01- )a _i <br />CONSTRUCTION TYPE I. SINGLE WALL Ci 2. DOUBLE WALL 3. NO DL4PE(NSERS Q 90. NONE 4�a <br />CONSTRUC170N iMATI3RiAL i. STTiEL 4. FIBERGLASS 10. RIO@ PLASTIC 99.OT HBR <br />VIII. CORROSM PRWECTION <br />STEEL COMPONENT PROTECTION © L SACRIFXXAL ANODE(S) D 4. IMPRESSED CURRENT AC& ISOLATION <br />UL APPLICANT SIGNATNE <br />CERTIFICAT70N: I axe fiat dill UST ayM M b caalNdbla *0 da limar4ow Slab m M ed W Wu tb fdermagarB pmvNad bards Is 01-1101. <br />APPLICANT SKiNATURE y • _ DATE/ L% 1 .' • . <br />Z / <br />/' D 1 <br />G' <br />APPLICANT NAME {pant) ""> 4TH. APPLICANT TITLE / ' t� <br />UPCF EW -B -1/2 Rim. (1301To7f <br />