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e <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) <br /> TYPE OF ACTION (Chock one item only. Fm an UST pcniumc t closure or remove[,complete only this section and Sections I,II,Iq IV,and IX below) 430 <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> EJ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: a3Oe DATE EXISTING UST DISCOVERED: 4396 <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use OWy) - G U <br /> BUSINESS NAME(Seale as FACIL AME or DBA-Doing Business As) 3 <br /> $C_rVJo,. iv/9 c <br /> BUSINESS SITE ADDRES 103 <br /> /?v Iro Y-c Rol CITY <br /> IL TANK DESCRIPTION <br /> TANK ID# 432 TANK MANUFACTURE 433 ��ITAAN'''K CONFIGURATION: THIS TANK IS 4M <br /> �;��/^� ` Cow 4-AIn A, " t Iq.A STAND-ALONE TANK <br /> Vq0C' 2.ONE IN A COMPARTMENTED UNIT. <br /> 1 C aeom for«h mm in the wue <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 4 NUMBER OF COMPARTMENTS IN THE UNIT 457 <br /> L ZD , vino <br /> M.TANK USE AND CONTENTS <br /> TANK USE 8 la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 <br /> 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Md Used Oin ❑ 5.EMERGENCY GENERATOR FUEL[HSC[252a13(e)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% <br /> CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ I b.PREMIUM UNLEADED 440 <br /> 3.DIESEL ❑ 5.TET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 4Wa <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUMS Wb <br /> IV. -TANK CONSTRUCTION <br /> .. <br /> TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL 195.UNKNOWN M3 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER qq4 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL In 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7AACKETED 445 <br /> ❑ 90.NONE 1395.UNKNOWN ❑99.OTHER 5 ): 445. <br /> OVERFILL PREVENTION I.AUDIBLE @ VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-0FF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑LSINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 4W <br /> SYSTEM TYPE I.PRESSURE ❑ 2.GRAVTTY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION DCCR$2636(a 31 458 PRIMARY CONTAINMENT 1.STEEL PS 4.FIBERGLASS ❑ S.FLEXIBLE ❑ I0.RIGID PLASTIC 464 <br /> ❑90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): aw <br /> SECONDARY CONTAINMENT ❑ L STEEL '4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ W.OTHER(Speclfy): 464c <br /> PIPINGRTIRBINE CONTAINMENT SUMP TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL [1 90.NONE 4644 <br /> VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT 0 1.STEEL 4.FIBERGLASS El 10.RIGID PLASTIC 0 90.NONE E3 99.OTHER(Specify) 464e <br /> 464 l <br /> VENT SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC C3 90.NONE 99.OTHER(Specify) 4W <br /> 46 Fl <br /> VR PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS 10.RIGID PLASTIC 13 90.NOMEO 99.OTHER(Specify) 469g <br /> VR SECONDARY CONTAINMENT 1.STEEL 9.FIBERGLASSE3 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) a6M <br /> 4Mhl <br /> VENT PIPING TRANSfITON SUMP TYPE Fl I.SINGLE WALLEl 2.DOUBLE WALL Da 90.NONE 464i <br /> RISER PRIMARY CONTAINMENT 1.STEEL U 4.FIBERGLASS U 10.RIGIDPLASTIC U 90.NONE E3 99.OTHER(Specify) 464j <br /> 4641 <br /> RISER SECONDARY CONTAINMENT 1.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4Wk <br /> 464k1 <br /> FILL COMPONENTS INSTALLED 1.SPILL BUCKET 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451. <br /> VII.UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE 29 L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS <br /> CONSTRUCTION MATERIAL I.STEEL 4.FIBERGLASS ❑ 90.NONE 469+ <br /> ❑ 10.RIGID PLASTIC ❑ ".OTHER(Specify) �a69bc <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT DT 6.ISOLATION � ..Ms. <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the[information provided herein is tru;�ac�ratq <br /> and N full compliance with legal recitalrements. <br /> APPLICANT SIGNATURE /J �� DATE (, .L L/ ��T 4'N. <br /> APPLICANT NAME(print) s 471' APPLICANT TITLE 4n <br /> .� r✓9/'J a// <br /> UPCF UST-B-1/2 <br /> Rev.(12/2007) <br />