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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per USI) TYP F ACTION (Check one item only. For an UST permanent closure or removal, complete only this section and Sections I, II, III, IV, and IX below) 430 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE Q 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 4-'0a DATE EXISTING UST DISCOVERED: 4306 L FACHJTYIINFORMATION FACILITY ID # (Agrsrcy Use Only) (Q BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Busmen As) 3 rML BU INESS SITE ADDRESS to3 CITY lea IL. TANKDESCRIPTION_ TANK ID # �` 432 V TANK MANUFACTURER 433 CONFIGURATION: TM TANK 1S 434 O3ZC1 ` r� OvO► C to - ?per , C. ' rCoa4gde A STAND-ALONE TANK / YjONE IN ACOMPARTMENTED UNIT. � Z 1 1 One page for eKh E02MMS5in the ML DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMP AR NTS IDLTHE UNIT 437 U IIL'TANK LTSE:ANI?_CE_ TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ ib. MARINA FUELING ❑ 1 C. AVIATION FUELING 430 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE a.1we Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL I §252815(c)I [16.OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ la. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ lb. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440a NON -PETROLEUM: ❑ 7. VSeU7611, ❑ 10. ETHANOL 041. OTHER NON -PETROLEUM ): L t L 44ob IV. ',:TANK CONSTRUCTION TYPE OF TANK ❑ L SINGLE WALL FLLfDOIJBLEWALL ❑ 95. UNKNOWN 443 PRIMARY CONTAINMENT . STEEL 3. FIBERGLASS 0 6. emmNAL BLADDER 444 P❑ 7. STEEL + INTERNAL LINING 95. UNKNOWN ❑ 99. OTHER (S 444a SECONDARY CONTAINMENT I. STEEL 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LIVER ❑ 7. JACKEfm- 445 ❑ 90. NONE ❑ 95. UNKNOWN [399.OTHER (S ): 445a OVERFILL PREVENTION 1. AUDIBLE B VISUAL ALARMS 0 2 BALL FLOAT ❑ 3. FILL TUBE SHUT-OFF VALVE 457 TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT_!: WASTE PIPING-9NSTRUCTION - - PIPING CONSTRUCRON M&SINGLE-WALLED 2 99.01HER 460 GRAVIDOUBLE-WALLED SYSTEM TYPE ❑ 2. TY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [?3 CCR §2636(ax3)I 458 PRIMARY CONTAINMENT STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(Specify): 464& SDCONDARY CONTAINMENT C3 I. STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99- OTHER (Specify): C C 464e PIPINGMURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL Ll 2. DOUBLE WALL 90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER/ FIId PIPE; PIPINGCUNSTRUMON: VENT PRIMARY CONTAINMENT STEEL 0 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE G 99. OTHER (Specify) 464a 464el VENT SECONDARY CONTAINMENT ❑ I. STEEL ❑ 4. FIBERGLASS 0 10. RIGID PLASTIC C1 90. NONE 0 99. OTHER (Specify) 464f 464n VR PRIMARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC Cl 90. NONE 0 99. OTHER (Specify) 4648 464 I VR SECONDARY CONTAINMENT ❑ 1. STEEL 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL 0 2. DOUBLE WALL 90. NONE 464L RISER PRIMARY CONTAINMENT Ll 1. STEEL 0 4. FIBERGLASS U 10. RIGID PLASTIC ❑ 90. NONE 99. OTHER (Specify) 464j 464' 1 RISER SECONDARY CONTAINMENT 1. STEE 4. FIBERGLASS 10. RIGID PLASTIC 90- NONE 99.OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED 13 1. SPIM BUCKET 3. STRIKER PLATEfBOTTOM PROTECTOR 0 4. CONTAINMENT SUMP 45la-c VM UMERDLSPENSM COMAII :(UDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL ❑ 2 DOUBLE WALL 133. NO DISPENSERS 469a CONSTRUCTION MATERIAL 1. STEEL Q 4. FIBERGLASS 10. RIGID PLASTIC E,99.OTHER( ' ) 469be VM CORROSIONI PROTECTION „. STIP COMPONENT PROTECTION ❑ 2 SACRIFICIAL ANODE(S) ❑ 4. DRESSED CURRENT 6. ISOLATION 44L UL APPLICANT SIG ATM . C13RT10FICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in fn Lance with legal requirements. APPLICANT SIGNATURE DATE 470. APPLICANT NAME (print)471_ G APPLICANT []TLE 4r_ 44t-IV� k(k - c:) vv UPCF UST -B - 1/2 Rev. (IL2007)