BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

Fm� n UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK U yt OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections[,II,III,IV,and I;(below) 430 ❑ 3RENEWAL PERMIT ❑ 1.NEW PERMIT' . 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: - I DATE EXISTING UST DISCOVERED: 430b 1. FACIIdTY INFORMATION FACILfI'Y ID#(Agency Use Only) TTHI BUSINESS ME(Same as FACIL(LY NAME or DBA-Doing Business As) 3 Z- 19- C :!� BUS[NE S SITE ADDRESS i97 CITY _ IN IL TANK DESCRIPTION TANK 1D##\/ 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 Tq l D Z I= ❑LONE N A COMPARATMENTED UNIT. Cpm' 7�2 c aeorc 6rmch in Newri[ DATE UST Sy 7E M TALLED 435 TANK C9PACf1Y IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 / S III.TANK USE AND CONTENTS TANK USE Q[-1a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(b.d Ua Oi0 ❑ 5.EMERGENCY GENERATOR FUEL[HSC 025281.5(c)1 ❑ 6.OTHERGENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: ra.REGULAR UNLEADED [3Ic.MIDGRADE UNLEADED ❑ 1 b.PREMIUM UNLEADED W 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S i : 44a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS i : y,sb IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL .DOUBLE WALL ❑ 95.UNKNOWN 413 PRIMARY CONTAINMENT 1.STEEL 13 3.FIBERGLASS ❑ 6.INTERNAL BLADDER qq4 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER is i SECONDARY CONTAINMENT ❑ 1.STEEL '03.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LM#� ❑ 7,JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN .OTHER(Specify), - ,// 445. OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS Z.BALL FLOAT 3.FB.L TUBE SHUT-OFF VALVE 453. Er 4.TANK MEETS REQUIREMENTS OR EXEMPTION FROM OVERF LL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE �-1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[U CCR§2636(a)(3)I 458 PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS .FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 469a SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS W.FLEXIBLE ❑ IO.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN t3 99.OTHER(Spxify): 464c PIPINGITURBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 469d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL NO 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 461e i VENT SECONDARY CONTAINMENT �c1 ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Spaify) 464f VR PRIMARY CONTAINMENT ❑ L 469Fl STEEL 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4Mg VR SECONDARY CONTAINMENT ❑ LSTEEL -4.FIBERGLASS ❑ In RIGID PLASTIC4641 ❑ 90.NONE 99.OTTIER(Specify) 464h 464h1 VEIN PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL O.NONE RISER PRIMARY CONTAINMENT 1.STEEL 4.FB3ERGLASS 10.RIGm PLASTIC 90.NONE 99.OTHER(Specify) 46aj RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464k 464Y1 FILL COMPONENTS INSTALLED I.SPILL BUCKET 3.STRIKER PLATF/BOTTOM PROTECTOR 4.CONTAINMENT SUMP 431nc VII.UNDE DISPENSER CONTAINMENT(MENSERN70NEi. CONSTRUCTION TVPE J.SINGLE WALL ❑ 2.DOUBLE WALL ❑ SERS ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL 0 4.FIBERGLAS$ 10.RIGID PLASTIC ❑ 'fy) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT -- SOLATION 448.IX. APPLICANT SIGNATURE CERTIFICATION: I certlII A t this UST sys"ig compatible with the hazardous substance stored and ation provided herein is true,aceurate,nR cweAPPLICANT SIGNATU r" DATE - Ota.APPLICANT NAME Q 471. APPLICANT TITLE, 4n.c- UPCF UST-11-1/2 mew t lvzaon