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AWUD PROGRAM CONSOLIDATED FORO MW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) shass"ZATE CTION (Check one item only. Foran UST pemfanent clostre or removal,complete only this section and Sections 1,IL III,N,and IX below) a3o PERMIT ❑ 3.RENEWAL PERMIT5.CHANGE OF INFORMATION ORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITES.UST REMOVAL PERMANENTLY CLOSED: 430a DATE E USTiNGUST DISCOVERED: a3on L FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ _ I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) Ji m co /1 vC'v_ BUSINESS SITE ADDRESS IU3 CITY n IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANKCONFIGURATION: TERSTANKIS 434 �j ❑❑1.ASTAND-ALONE TANK // ��// M 2,ONE 1N A COMPARTMENTED UNIT. (AYN K-v10 Ujo - U lereaee foram eof is the wit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 (.� oc III.TANK USE AND CONTENTS TANK USE Ia MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ la AVIATION FUELING 439 ❑ 3.CIEWCAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Wdm Uxd Oil) [3 S.EMERGENCY GENERATOR FUEL TJLSC.§]281.5(e)I Q 6.OTHERGENERATORFUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Spedfy): 43% CONTENTS PETROLEUM la REGULAR UNLEADED ❑ 1c. IDGRADEUNLEADID ❑ Ib.PREIv"UNLEADED °40 ❑ 3-DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 440a ❑ 8.PETROLEUMBLEND FUEL 99.OTHELPEIROLEUM (S NON-PETROLEUM❑ 7.USED OIL ❑ 10.ETHANOL n4W ❑ 11.OTHER NON-PETROLEUM S W. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL X i.IXIUBI.E WALL ❑ 95.UMU40WN 643 PRMIARYCONTAINMENT I.STEEL Q 3.FIBERGLASS ❑ 6.INTERNAL BLADDER IN 7.STEEL+ TERNAL LINING ❑ 95.UMINOWN ❑ 99.OTHER (specify): 444a SECONDARY CONTAINMENT 1.STEEL ❑3 FIBERGLASS ❑ 6.EXTERIOR MEdBRANE LINER 0 7.JACKETED 4a5a rT 9o.NONE [] 95.UNKNOWNoTHER(s Y OVERFILL,PREVENTION I.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 4sz. ❑ 4.TANK MEECS REQUIREMENTS FOREXEMPHONMIMOVERFB,L PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOURLE-WALLED ❑99.OTHEt 460 SYSTEM TYPE J9 I.PRESSURE Ll2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTRNT P3 CCR§2636(n ➢ 458 PRIMARY CONTAINMENT ❑ 1-51EEL m4.FIBERGLASS ❑ 8.FLEMBI.E ❑ lo.' uw PLA577C 464a ❑ 90.NONE ❑ 95.UNKNOWN Q99.OHER(SpeatS): a b SECONDARY CONTAMhtENI ❑ I.STEEL J&4.FIBERGLASS 0 &FLEXIBIS ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(SIwiTY): a6W PIPINGI TURBINE CONTAINMENT SUMP TYPE IN-1.SINGLE WALL ❑ 2 DOUBLE WALL [3 90.NONE x VL VENT,VAPOR RECOVERY(VR)AND RISER/FELL PIPE PIPING CONSTRUCTION VENC PRIIKARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS - ❑ I0,RIGID I+i.AS17C El90.NONE L] 99.OTHER(Specify) °N4 a6ae1 46 VENC SECONDARY CO; =l ;I ii if 1] I.STEEL ❑ 4.FBERGLASS 10.RIGID PLASTIC ''.90.NONE Ll99. :) :IDI: SP�3�') a64n VA PRIMARY CONTAINMENT' ❑ I.STEEL 4.FBFRGI,ASS El10.RIGIDPLASTIC 0390.NONE 99.OTHER(Speafy) 464g 464 I 1.STEEL ❑4.FIBERGLASS ]0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) - VRSECONDARYCONTAWMEJ'I' 46ah1 a64t VENTPIPINGTRANSITION SUMP I PE ❑ 1.5INGLE WALL ❑ 2.DOUBLEWALL 90.NONE 464jRISER PRENON ARY CTAINMENT -K1.STEEL ❑ 4.FBERGI:ASS ❑ 10.ALGID PLASTIC ❑ 90.NONE LJ W.OTHER(Specify) 4"] RISER SECONDARY CONTAAIbfENT ❑ 1.STEEL E] 4641 4.FIBERGLASS ❑ ]O.RLGIDPLASTIC 90-NONE 99.0-CtiERA(Specify) 4641 FILL COMPONENTS INSTALLED .SPILL BUCKET ❑ 3.STRIIa;RPLATF/BOTTOM PROTECC(9R ❑ 4.CONTAINMENT SUMP 451" VII.UNDER DISPENSER CONTAINMENT(f1DC) 469a CONSTRUCTION TYPE I.SINGLE WALL 13 2-DOUBLE WALL ❑ 3.NODISPF&'SFRS ❑ 90.NONE4 CONSTRUCTION MATERIAL. ❑ 1.STFII. ❑ 4.FIBERGLASS ❑ I0.RIGID PLASTIC ❑ W-V I IDt(S ) VIIL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2 SACRIFICIAL.ANODE(S) ❑ 4.1MPRFSSED X6.ISOLATION LY. APPLICANT SIGNATURE ,x CERTIFICATION: I certify that this UST system is rnmpatible with the hazardous sabstssce stored and that the information provided hereias true,accurate, and in fall eom Bance with 1 uiremenls. 470. A�dCANT SIGNA DATE a7. 471' APPLICANT TTFLE AP CANT NAME Rev.(1=007) UPCF UST-B-12