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UNIFIED PROGRAM CONSOLIDATED FORM I -3 - UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one fora per UST)yp l(/j; ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections I, I7, III, IV, and IX below) L17 I. rvnw rrxmll U J. KtNbWAL FERWF U 5. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE 7. UST PERMANENT CLOSURE ON SITE 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. DATE EXISTING UST DISCOVERED: 43% I. FACMITY INFORMATION FACILITY m # (Agency Use Only) 1 cz BU INESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 BLJSP.41ESS SITE ADDRESS t03 CITY �. • lea IL TANK DESCRIPTION TANK ID # 7'/) 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS � I � "-- 434 9y1/ �~ ❑ 1. STAND-ALONETANK l `I �Comvk�INACMPARTMENTID� `U��G1�IC DATE UST SYSTEM -INSTALLED 4JS TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 ZJD III. T141W-UW414iM CONTENTS TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING 13Ic. AVIATION FUELING 439 E33. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (lodude Used Oil) ❑ 5 GE ICY GENERATOR FUEL (HSC 1232813(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95. UNKNOWN OTHF1t ( ); 439a CONTENTS PETROLEUM: ❑ In. REGULAR UNLEADED ❑ la 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: ❑ 7. ED OIL ❑ 10. ETHANOL �y / I.OTHERNON-PETROLEUMS ' �T� 440b IV.'. TANKCONSTRUC. nON TYPE OF TANK Q I-MNGLE WALL Url DOUBLE WALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT &M STEEL 0 3. FIBERGLASS ❑ 6. INTERNAL BLADDER 444 ❑ 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (S 444a SECONDARY CONTAINMENT ❑ I. STEEL ❑ 3. FIBERGLASS ❑ 6. EXTERIOR MIafBRANE LINER ❑ 7. JACKETED 445 ❑ 90. N0 ❑ 95. UNKNOWN 99, OTHER ( ): ,c'„� L;"•:% 445a OVERFILL PREVENTION I. IBI E $VISUAL ALARMS 2. BALL FLOAT 3. FILL TUBE SHUT-OFF VALVE 452 TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCTai WASTE PIPING CONSTRUCTION - PIPING CONSTRUCTION . SINGLE-WALLID2.DOUBLE-WALLED ❑ 99.OTHER 460 SYSTEM TYPE URE ❑ 2. GRAVITY 3. CONVENTIONAL SUCTION 4. SAFE SUCTION r23 CCR 12636h)(3)1 458 PRIMARY CONTAINMENT . STEEL 0 4. FIBERGLASS 0 8. FLEXIBLE 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ L STEEL 0 4. FIBERGLASS ❑ S. FLEXIBLE E3 I0. RLGm PLASTIC 4646 ❑ 90. NONE ❑ 95. UNKNOWN 99.OTHER (Specify): C"'. erirs e- (: %l 467. PtPINGM1RBINE CONTAINMENT SUMP TYPE 1. SINGLE WALL ❑ 2. DOUBLE WALL 90. NONE 4644 -.VL-VENT, Y: POR COVERY (VR) AND RISER/ FILUPIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT . STEEL U 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 0 99. OTHER (Specify) 464e VENT SECONDARY CONTAINMENT 1. STEEL 4. FIBERGLASS 0 10. RIGID PLASTIC El 90. NONE 0 99. OTHER (Specify) 464f 464r VR PRIMARY CONTAINMENT 13 1. STEEL 4. FIBERGLASS 13 10. RIGID PLASTIC 0 90. NONE r3 99. OTHER (Specify) 4649 1 VR SECONDARY CONTAINMENT I. STEEL 4. FIBERGLA 0 10. RIGID PLASTTC 90. NONE 13 99. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE I. SINGLE WALL 2. DOUBLE WALL 90. NONE 464L RISER PRIMARY CONTAINMENT Lj L STEEL 0 4. FIBERGLASS U 10. RIGID PLASTIC El 90. NONE 0 99. OTHER (Specify) 464) 467'1 RISER SECONDARY CONTAINMENT 0 L STEEL 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 99.OTHER (Specify) 464k 4641 FILL COMPONENTS INSTALLED 0 L SPILL BUCKET 3. STRIKER K ATFJBOTTOM PROTECTOR Ej 4. CONTAINMENT SUMP 451a•c VII. UNDER DISPENSER CONTAINiMENT.(UDQ CONSTRUCTION TYPE ❑ L SINGLE WALL ❑ 2. DOUBLE WAIL ❑ 3. NO DISPENSERS . NONE 46% CONSTRUCTION MATERIAL ❑ L STEE 0 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99. OTHER (S ) 469bc VIII_ CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT 6. ISOLATION 448• UL APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible, with the hazardous aebshaee stored red that the information Provided herein is tree, accurate, a" L fulLvaugazate With legal requirments. APPLICANT SIGNATURE DATE 470. �" Li•�v APPLICANT NAME (print) 471.,APPLICANT TITLE 472. zl-wl vo ic 0A UPCF UST -B - I!2 Rev. (I V2007)