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• • ri F UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION -TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal, complete only this section and Sections 1,11,111, IV, and IX below) K15Mf 37 g,5. CHANGE OF INFORMATION C 1 ❑ I. NEW PERMIT [:13. RENEWAL PERMIT ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED. 43°. 1 DATE EXISTING UST DISCOVERED: 4301,. I. FACILITY INFORMATION FACILITY ID 4 (Agency Use Only) 1. ESS NAME (Same as Facility or DBA - Doing Business As) 3. nBU �Name ` ©�L LJt /I /l cOzl E.Q /ice [s'�1' rf�ISTYYG� a"'[iE BUSINESS SITE A SS 103 15"33 Zl s� sf CITY IN �Sl ocs�T�n IL TANK DESCRIPTION TANK ID 4 Z kq 432, TANK MANUFACTURER 433. TANK CONFIGURATION: THIS TANK IS 434. ``/� r7 311 /�J "� �r�! 191. ASTAND-ALONE TANK Complete one po, for eecb lKO0Z dGIJe )S ❑ 2. ONE INA COMPARTMENTED UNIT rumpmmtent in the mit. DATEUST SYS EM INSTALLED 435. TANISCAPAACIT IN GALLONS 436. NUMBER OF CVRTMENTS IN THE UNIT 431 �! GGIIII.. TANK USE AND CONTENTS TANK USE la. MOTOR VEHICLE FUELING ❑ Ib. MARINA FUELING ❑ la AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Fueled. Used Oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §252a1.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439. CONTENTS PETROLEUM: ❑y la. REGULAR UNLEADED ElIc. MIDGRADE UNLEADED ❑ Ib. PREMIUM UNLEADED 440 . Jul 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 44o. NON -PETROLEUM [1 7. USED OIL ❑ IQ ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify), "Ob IV. TANK CONSTRUCTION TYPE OF TANK ❑ I. SINGLE WALL 2. DOUBLE W ALL ❑ 91 L NKNOWN 443_ PRIMARY CONTAINMENT ❑ 1. STEEL Jb 3. FIBERGLASS ❑ 6 INTERNAL BLADDER 404 ❑ 7. STEEL+ INTERNAL LINING ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ 1. STEEL X3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER(SIISf : 445. OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS ❑ 2. BALL FLOAT 53. L TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVFILENTION E UIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE WALL .DOUBLE WALL ❑ 99. OTHER 460. SYSTEM TYPE A 1. PRESSURE ❑ 2. GRAVITY If 3 CONVENTIONAL SUCTION_ ❑ 4 SAFE SUCTION 23 CCRiiIielill 058 _ PRIMARY CONTAINMENT ❑ 1. STEEL LK4. FIBERGLASS ❑ 8. FLEXIBLE C]10. RIGID PLASTIC 464. ❑ 90. NONE EJ 95. UNKNOWN ❑ 99. OTHER(Spe_cify):_ _464% _ SECONDARY CONTAINMENT ❑ 1. STEEL RL 4. FIBERGLASS ❑ 8_FLEXIBLE ❑ 10. RIGID PLASTIC 46,1& ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Spec_fy): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1. SINGLE WALL CK 2. DOUBLE WALL ❑ 90. NONE 464a. VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 1 STEEL ❑ 4. FIBERGLASS ❑ 10 RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 4464e VENT SECONDARY CONTAINMENT I STEEL ❑ 4. FIBERGLASS [1 10. RIGID PLASTIC El 90, NONE El99. OTHER (Specify): 6411. - VR PRIMARY CONTAINMENT I$ 1. STEEL ❑ 4 FIBERGLASS EI10 RIGIDPLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): j6A4 VR SECONDARY CONTAINMENT 99 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464h1. 4 97 VENT PIPING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL ❑ 2 DOUBLE WALL 90. NONE _ d4: RISER PRIMARY CONTAINMENT 1. STEEL El 4. 4. FIBERGLASS 10 RIGID PLASTIC 90. NONE 99. OTHER (Specify): 464, RISER SECONDARY CONTAINMENT 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 46 kk 1. FILL COMPONENTS INSTALLED 1. SPILL BUCKET ❑ 3. STRIKER PLATEBOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP 451 - VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE 29 1. SINGLE WALL ❑ 2. DOUBLE WALL 3. NO DISPENSERS ❑ 90. NONE _ _D "b CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS ,III RIGID PLASTIC ❑ 99. OTHER (Specify) 4469, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODES) ❑ 4. IMPRESSED CURRENT ❑ 6. ISOLATION 448. IX. 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 an full compliance with legal requirements. APPLICANT SIGNATURE DATE Oro ��6 dJ� . 4n' APPLICANT NAME(prin[) �/"'C'f� L APPLICANT TITLE F�Cle�j/4Gf S ry.rP`4aeC�47!-"= D UPCF UST -B Rev. (122007) -1/2 www.unidocs.org'�