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10/03/2007 09:40 #0050 P.008 /021 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(O►le form per UST) M1111111111-TYPE OF ACTION (Cho*one item only_ For an UST perm hent closure Or Lt:m0-1,compkW 0211y this section and Scctioas I.II;III,IV,and IX below) 430 [] 1.NEW PERMIT 3.RENI?WAL PERMIT ❑ 5.CFIANGF OF INFORMATION ❑ 6•TEMPORARY UST CL.OSbRE 7,UST PERMANENT CLOSURE ON SITE a8.UST REMOVAL, DATE UST PERMANENTLY CLOSED; 430a DAl"E EMSTING UST DISCOVERED- 430b . FACILITY INFORMATION FACILITY ID#(Agmrc),Use Only) t BUSINESS NAME(Same as FACILITY NAME pr DT3A- Bty4i As) 3 F:i BUSINESS SITE ADDRESS L03 CITIf104 IL TANKDESC RIPTION' .: TANK ID# 432 TANK MANUFACTIJRFR 4.13 TANK CONKOURATION:TIM TANK IS 434 /� ` V//,,V��11 t�.I.A STaND-.a WNE TANK V J 0 +{_y 2.ONE IN A COMPART IE2\'ED UNIT, C4 ane forBlrR4om mt UVIL DAT);UST SYSTEM STALL ED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 in.TANK'USE AND CONTENTS '. TANK USE 50 1a,MOTOR VE1-UCLEPUELLNG Q Ib.MARINAFLMLING © Ic.AVIATION FUELING 439 Q 3.CMUCAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(babbas Used on) Q 5.EMERGENCY GENERATOR FUEL.LFLCC$2S28t.5(e)j ❑ 6.CITHF,R GENERATOR FIJI. C] 95.UNKNOWN ❑ 99.CYTHER(Speriiy): 4394 CONTENTS PETROLEUM ❑ la.REGULAR UNLEADED ❑ 1 c.MIDGRADE UNLEADED ❑ lb_PREMTUM UNLEADED 440 3.DIESEL Q S.JET FUEL ❑ 6.AVIATION GAS S.PETROLEUM BLEND FUEL, ❑ 9.OT14CR PETROLEUM s ) 440a NON-PETROLEUM:L] 7.USED OIL ❑ 10.ETHANOL ❑ 1 I.OTHER NON-PETROLEUM S a406 IV. TANK CONSTRUCTION TYPE OF TANK I.SINGLE WALL 2.DOUBLE WALL Q 95.UNKNOWN 443 PRIMARY CONTALNMEIIT � I.STEEL El3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 7.STEEL_INN ERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S 444a SECONDARY CONTAINMENT ❑ 1.STEEL. IC3,FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKEITA 445 ❑ 90.NONE ❑ 95.UNKNOWN 0199.OTHER(Sperif): 445a OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS Q z TjALL IZOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OV..MUUL,PREVENTION EQUIPMENT V..PRODUCT I WASTE,PIPING CONSTRUCTfON PIPING CONSTRUCTION Q L.SINGLE-WALLED IU 2.DOUBLE-WALLED ❑99.OTHI-M 460 SYMPA TYPE I.PRESSURE ❑2.GRAVITY E33.CONVENTIONAL SUCTION ❑4.SAFE SUCTION m CCR 41636(m)(3) 458 PRIMARY CONTA.IN-MF.NT ❑ I.sTF35L P1 4.FMERGLASS a S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE, ❑ 95.UNKNOWN ❑ 99.OTHER(Spedfy); 464a SECONDARY CONTAINMENT ❑ I.STEEL ®4_FIBERGLASS ❑ 8.F=TBLE p 10.RIGID PLASTIC 464b Q 90.NONE 0 95.UNKNOWN ❑99-OTHER(Specify): 464c PIPIN011'URBINE CONTAINMENT SUMP TYPE IS I.SINGLE WALL ❑ 2.DOUBLE WALL 13 90.NONE 4644 VI..VENT,VAPOR RECOVERY(VR};AND.RISER/'FILL PIPE'PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 11 1.STEEL. 4.FIBERGLASS 10.RIGID PLASTIC 90.NOA'E99.UTLdER(Specify) 464e VENT SECONDARY COAT[AINMENT' ❑ L.STEEL 4,PFBERGLASS ❑ 10.1tLGLD PLASTIC ❑ 90.NONE ❑ 99.OTHER(Speci('y) 464r 4d4fl VP PRIMARY CONTAINMENT ❑ 1.STEEL bO 4.F ❑ t0.RIGID PLASTIC Q 90.NONE 99.OTHER(Specify) 4648 ___4646, VR SECONDARY CONTAINMENT 0 1.STEEL. 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 90.NONE-E79-9.OTHER(Specify) 164b VENT'PIPING TRANS LTTON SUMP NPL 1.SINGLE W.4L.L [12.DOUBLE WALL 464L1 90.NONE 464;. RISER PRIMARY CONTAINMENT Lj 1.STEEL- [j 4.FIBERGLASS 10.RIGID PLASTIC El 90.NONE Q 99,OTHER(Specify) 464j RISER SECONDARY CONTAINMENT ❑ 1.STEEL 54 4.FIBERGLASS ❑ !0.RIGID PLP,STIC ❑90.NONE 0 99.OTHER(Specify) 464k 464kt FILL COMPONENTS lNSTALLi7? 1.SPILL RUCKET 3.STRIKER PLATFJBOTTOM PROTECTOR 4.CONTAINMENT SUMP 45ta.r VII,U1NDEILDISPENSERCONTAINMENT(UI)C) CONSTRUCTION TYPE 1.SINGLE WALL [12.DOUBLE WALL ❑ 3.NO DISPENSER$ [] 90.NONE 46% CONSTRUCTION MATERIAL 1.STEEL. ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Sp=*) 469b4 VIII.'.CORROSION-PROTECTION STEEL COMPONENT PROTECFt ❑ 2.SACRIFICIAL ANODES) ❑4.IMPRESSED CURRENT Q 6.ISOLATION 448. 1X APPLICANT SIGNATURE CERTIFICATION:I cerd(r t titin U System' w patlbie with the hazardous sobs uaft Stored and that the Information provided herein Is&ue,$ccurate, aad in fu Com . whb 1 ujtc um APPLICANT SLCrNATCTRE; DATEPLA r 470. l ll APPLICANT NAME(print) 471. APPLICANT TITLE 472 UPCF USC-8-V2 Rev.(1212407)