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X72�a� veL, Y'F / rUvr�a ,�95( 70� u1, 0 i UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK RJ _ _ OPERATING PERMIT APPLICATION-TANK INFORMATION(or.loanIx,us7) ACTION (Check one iterr,only. For an UST pe"nane0lCIOSM a removal,Complete only this section and Sections L IL III,N,and IX below) 430 PERMIT ❑ 3.RENEWAL PERMIT 5.CIlANGE OF INFORMATIONPORARY UST CLOSURE I.UST PERMANENT CLOSURE ON SITE R.UST REMOVAL T PERMANENTLY CLOSED: °Hp DATE EXISTING UST DISCOVERED:I. FACILITY INFORMATION ID p(Agency Use On1y)S NAME(Same as FACILITY NAME orDBA-DoingBusinessAs)STfE ADDRESS_ IID`eCRY Ce: la IL TANK DESCRIP7TON 432 TANK MANUFACTURER 435 TANK CONFIGURATION: THIS TANK Is W ❑ILA STAND-ALONE TANK r ll( .ONE M A CO PARTMENfED ONTr. DATE UST SYSTEM INSTALLED 435 T CAPACITY IN GALLONS am NUMBER OF COMPARTMENTS IN THE UNIT 437 K 2J M.TANK USE AND CONTENTS TANK USE 4RN MOTOR VEHICLE FUELING ❑ I b.MARINA FUELING ❑ ICAVIATIONFUELING 439 ❑ 3.CHEMICAL PRODU CT STORAGE ❑ 4.HAZARDOUS WASTE(,, Iu tlw4Oin ❑ S.EMERGENCY GENERATOR FUELSD 6=S18nS1c11 ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99,OTHER L DISC(S * ): 43% CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Ir-MIDGRADE UNLEADED ❑ IG PREMIUM UNLEADED sw 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS 9.PETROLEUM BLEND FUEL [39.OTHER PETROLEUM S aam NON-PETROLEUM:El T.USED OIL ❑ 10.ETHANOL - ❑ 11.OTHER NON-PETROLEUMS 440e IV. TANK.CONSTRUCTION. TYPE OF TANK ❑ I.SINGLE WALL 752.DUUBLEWALL ❑ 95.UNKNOWN 4G PRIMARY CONTAINMENT ❑ I.STEEL tJ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER a44 ( ❑ I.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ W.DINER (S 4aw SECONDARY CONTAINMENT ❑ 1.STEEL �3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7AACKE ED 44s ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER 3 ): 44s OVERFILL PREVENTION I.AUDIBLE d VISUALAIARMS U 7BAL.FLOAT JK 3.FILL TUBE SHUT-OFF VALVE 4Q ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQiLWMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑L SINGLE-WALLED7 DOUBLE- ❑99.OTHE L 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVWALLED ITY 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION MOCR 02a3qaX3) 4si PRIMARY CONTAINMENT ❑ t.STEEL 2L 4.FIBERGLASS 8.FLEXIBLE U 10.RIGID PLASTIC 461 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHFR(Sp cify): 4644 SECONDARY CONTAINMENT' ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE 10.RIGID PLASTIC 4611, ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464 PIPI4GMUfRBINE CONTAINMENT SUMP TYPE .SINGLE WALL 2-AT ATM WALL W.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Spiny) - 461e 4641 VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Spaiy) 4M! 461n VR PRIMARY ZM INMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4649 VR SECONDANTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 9Q NONE 99.Of3ffR(Spe4iy) 460 4601 VENT PIPING ON SUhfP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 1,6°: RISER PRIMARY CONTAINMENT 1.STEEL U 4.FIBERGLASS U 10.RIGID PLASTIC U W.NONE Lj ".OTHER(Speuly) +1,j 46 1 RR SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10,RIGID PLASTIC 90.NONE 99.OTHER(Specify) 460 46411 FIISELL COMPONENTS INSTALLED Cl I.SPILLBUCKET 3.STRIKER PLATEIBOTTOM PROTECTOR 4.CONTAINMENT SUMP 451.c VII.UNDER DISPENSER-CONTAINMENT.(UDC). CONSTRUCTION TYPE .SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46ri CONSTRUCTION MATERIAL I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 99.OTHER(S ) 4696c VIII. CORROSION.PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 441, IX. APPLICANT SIGNATURE CERTIFICA'RON: 1 certify that this UST system it compatible with the haTardous 9ubstaace stored aad that the information provided herein I,bnt attoralq and in full aro Bance with legal regutimufants. .APPLICANT SIGNATU DATE - 4R h 2 G� APPLICANT NAME(print) °II' APPLICANTTITLE 41,. pf e� UPCF UST-B- 1/2 - Rev.(ILZBW)