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(�) qv-) )d ri UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK I O� OPERATING PERMIT APPLICATION -TANK INFORMATION (one form per UST) TF ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections 1, 11, 111, IV, and U( below) 430 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE El 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: 4306 L FACH= INFORMATION FACILITY ID # (Agency Use Only) BU$INESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 .� v ,��. �v� \�.� 5 L' --'or k l I14) BUSINESS SfrkADDRESS103 rr CY a Lh k s R c k C� •.l IL TANKDESCREMON ` TANK ID 432 TANK MANUFACTUM433TANK CONFK URATION: TIS TANK IS �4 GONE ,,,' j o3 ❑ 1. AND -ALONE TANK IN A COMPARTMENTED UNIT. 1 ISL v, ke Compicte one paw for aeb campaMnent m the =L DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF CO ARTMENTS IN THE UNIT 437 III. TANK USEA1%.0©1�ITENTS` TANK USE ❑ la MOTOR VEHICLE FUELWG ❑ Ib. MARINA FUELING ❑ lc. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (tadu In U d Oil) ❑❑ 55. MERGENCY GENERATOR FUEL CHSC §2528 t.5(c)) ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ER-%. OTHER (Specify): 43% CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ lc. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8_PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM S 440a NON -PETROLEUM: GF7. USED OIL ❑ 10. ETHANOL 11. OTHER NON -PETROLEUMS ): V v 4406 IV. TANK CONSTRUCTION . TYPE OF TANK ❑ 1._SINGLE WALL 2. DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT 1. STEEL ❑ 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (S 444a SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN99.OTHER (S ): 445a OVERFILL PREVENTION 1. AUDIBLE & VISUAL ALARMS Z BALL FLOAT 3. FILL TUBE SHU17-017 VALVE 452. 94 TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUWMMq T owl V PRODUCT I WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION l GLE-WALLED 2. DOUBLE -WALLED ❑ R OTHER 460 SYSTEM TYPE EVIPRESSURE C3 2 GRAVITY 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION I'-3 CCR §2636(a)(3)] 458 PRIMARY CONTAR04Ebrr Eirl. STEEL ❑ 4. FIBERGLASS 13 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAROAENr ❑ L STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE 0 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN 4 99. OTHER (Specify): ' C 464c PIPINGfrMINE CONTAINMENT SUMP TYPE 1. SINGLE WALL ❑ 2. DOUBLE WALL 90. NONE 4644 _:VI: VENT, YAPUR . COVERY`(VR)-AND RISER / RII,I PIPE. PIPING_ CONSTRUCTION _I07-13 VENT PRIMARY CONTAINMENT Ukl. STEEL 0 4. FIBERGLASS 11 PLASTIC 0 90. NONE 99. OTHER (Spm*) 464e 464e1 VENT SECONDARY CONTAINMENT 0 1. STEEL 0 4, F113ERGLASS 10. RIGID PLASTIC C3 90. NONE 99. OTHER (Specify) 464f 464f1 VR PRIMARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS 10. RIGID PLASTIC ❑ 90. NONE 99.OTHER (Specify) 464, 464 I VR SECONDARY CONTAINMENT 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Specify) 464h .1 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL C3 2. DOUBLE WALL 90. NONE 464L RISER PRIMARY CONTAINMENT 1. STEEL C7 4. FIBERGLASS ❑ 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 4641 4W'1 RISER SECONDARY CONTAINMENT 1. STEEL 4. FIBERGLASS 0 10. RIGID PLASTIC 90. NONE 99. OTHER (Specify) 464k 464kl 464k1 FILL COMPONENTS INSTALLED 13 L SPILL BUCKET 13 3. STRICEIt PLATFIBO TOM PROTECTOR 4. CONTAINMENT SUMP VM UNDER'DLSPENSER CONTAII�TMENT.(UDC}, CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS kf 90. NONE 46% CONSTRUCTION MATERIAL 0 1. STEEL El 4. FH ERG[ASS lo. RIGID PLASTIC 99.OTHER { ) 469bc VIIL CORROSION PROTECTION STEEL COMPONENT PROTECLiON ❑ 2. SACRiRciAL ANODES) ❑ 4.9A%ES.SED CURRENT 6. ISOLATION 448. TIL APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, MW in fail cunpliance with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME (print) r Zkn- 471' APPLICANT TITLE 47_ UPCF UST -11 - 1/2 Rev. (12/2007)