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P.5 61 SIFIED PROGRAM CONSOLIDATED F 'd (,47-10 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) 430 TYPE 4F ACTI::ON (Check one item only. For an GST permanent dosurc or removal,complete only this section and Sections 1,11,111,IV,and IX below) ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL 430b DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOV RED: I. FACILITY INFORMATION I FACILITY 1D#(Agency Use Only) 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) p gni 496CY 104 BUSINESS SITE ADDRESS 103 CITY r IL TANK DESCR]PTION 432 433 434 TANK'ID# � �S 'CANKIrtANCFACTURER TANK THIS TANK IS ❑ 1.A STAND-ALONETANK -S/ e j J 2.ONE 1-4 A Tv1ENTEU UNIT. G Com �a�e e for-com .ent in the unit. 437 DATE UST SYSTE INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT M.TANK USE AND CONTENTS TANK USE I a.MOTOR VEHICLE FUELING ❑ I b.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHE_vt[CAL PRODUCT STORAGE [34.HAZARDOUS WASTE[].dudes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[NSC§2T81 5(e)] 439a ❑ 6.0rHERGENERATOR FUEL ❑ 95.UNKNOWN ❑ 49.OTHER(Specify): CONTENTS PETROLEUM: ❑ Ia.REGU:.ARUNLEADED [3Ie.MIDGRADEU �.I�r•UN Ai Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS 440a ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL 4401, ❑ i 1.OTHERNON-PETROLEUM(Specify): IV TANK CONSTRUCTION. • 443 TYPE OF YANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 4" PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ &INTERNAL BLADDER 444a 7.STEEL+INTERNAL LINING ❑ 45.U�KNOl1'N ❑ 99.OTHER (Sped` 445 SECONDARY CONTAINMENT ❑ I.STEEL 3.FIBERGLASS ❑ 6_EXTER[ORMEbiBRANE LINER [37.JACKETED a452 ❑ 9o.N0NL ❑ 95.UNKNOWN ❑99.OTITER( .if-' 452. OVERFILL PREVENTION L AUDIBLE&VISUAL ALARNIS 2.13.4.LL FLOAT 3.FILL TUBE SHUT-OFF VALVE ❑ a.TANK MEETS REQLZREVIENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT 1 WASTE PIPING CONSTRUCTION 460 PIPING CONSTRUCTION ❑1.SINGLE-!WALLED 2.DOUBLE-WALLED ❑99.OTHER SYSTEM TYPE 1.PRESSURE 1-12.GRAVITY ❑ 3.CONVENTIONAL Sl CCION ❑ 4.SAFE SUCTION 123 CCR 4153 60)(3)] 4464 PRIMARYCONTA[NbiENT ❑ L STEEL 4.FIBERGLASS ❑ 3.FLEXIBLE ❑ 10.RIPLASTIC 464a ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Spxify): 464bSECONDARY CONTAIVMENT ❑ 1.STEEL I1� 4.FIBERGLASS Ll 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464e [❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)' 4646 PIPINa,-rURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL LJ90.\ONE VI.VENT,VAPOR RECOVERY{VR)AND RISER!FILL PIPEPII'ING COiSTRiTGTION . VENT PRIMARY CONTAINIAIENT 1.STEEL 4.FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90.VOLAE ❑ 49.OTHER(Specify) 46 (Specify) 46ar VENT SECONDARY CO.NTADTMENT {� 1.STEEL 4.FtBERGI ASS 10.A[G1D PLASTIC 40.VOLAE ❑ 99.OTHER464n VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS I0.RIGID PLASTIC 90.VONE Ll 99.OTHER(Specify) 46� aha 1 VR SECONDARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC C1 90.NONE ❑ 99.OTHER(Specify) 4641: 464111 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE 1VALL 40.VOLAE ' RISER PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC Ll 90.NONE 99.OTHER(Specify) 464J 464'1 RISER SECONDARY COhTA[t mEVT F-11.STEEL Ll 4-FIBERGLASS El 10.RIGID PLASTIC 90.vONE 99.0CHER(Specify) 464L 46441 FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATE*BOTTOHI PROTECTOR :1'4.CONTAINMENT SUMP 451a< VII.U.NDERIDISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE I.SINGLE WALL L] 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ I0.RIGIDPLASTIC ❑ 99.OTHER(Specify) VIII.!CORROSION PROTECTION. - STEEL COMPONENT PROTECTION [_12.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT [16.ISOLATION 448 IM-., APPLICANT SIGNATURE CERTIFICATION. f certify that this LIST stem is compatible with the hazardous substance stored and that the information provided herein is true,accurate. and in full cDrnDIiancvv9th legal requirements._ azo APPLICANT SIGNATURE DATE / O 'b 471 APPLICANT NAME(print) UPCF LST-B-112 Rev.(]2!2007)