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UNIFIED PROGRAM CONSOLIDATED FORM UINDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(cue fmm per UST) TYPE OF ACTION (Cheek we item ody. Fm an UST permanent-toluene or tele0val,complete Doty tins Section and Sections I,B,H4 N,and DC below) a" ❑ I NEW PERMIT 3 RENEWAL PERMIT F 5.CHANGE OF WFORM4ATION b.TEMPORARY UST CIASURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL 4MDATE UST PERMANENTLY CLOSED: DATE EXISTING UST DISCOVERED: L FACHIWINFORMATION 1 FACILITY ID#(Agency Use Only) - - BUSINESS NAME(Sears:as FACH.TIY NAME or DBA-Doing Basmeas Aa) 3 BUSINESS SITE ADDRESS 10ICITY Ia IL TANK DESCRIPTION TANK1.AsTAND-ALONE TANK ID# 432 TANK MANUFACTURER 033 TANXCONFIGURATION:TMTANKM � 4M NE IN A eev ficMCOMP DU �. DATE UST SYSTEM INSTALLED 435 T CAPACITY INGALIANS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 / OZ7 ULTANKUSEAND CONTENTS TANK USE Ia MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING 0 Ie AVIATION FUELING 439 3.CHEMICAL PRODUCT STORAGE 04.HAZARDOUS WASTE(IPd4ce Uaet Oa) 05.EMERGENCYGENERATORFU¢R6C42 l-gc)I 0 6.OTHERGENFRATOR FUEL 0 95.UNKNOWN 13 99.OTkIBR(S ): 439a CONTENTS PETROLEUM: ❑ la REGULAKUFEEADED 0 I.MII30RADEUNLEADED Ib.PREMIUM UNLEADED 440 0 3.D[ESEL 0 5.IEr FUEL 0 6.AVIATION GAS a10d 0 a.PETROLEUM BLEND FUEL. 0 9.OTHER PETROLEUM S NON-PETROLEUM:0 7.USED OIL 0 30.ETHANOL 11.OTHER NON-PETROLEUM(Sp=&). IV...TANKCONSTRUMON_ - TYPEOFTANK 01.SINGLE WALL 0 2.DOUBLE WALL 0 95.UNKNOWN 441 PR04ARY CONTAINMENT ❑ I.STEEL A 3.FIBERGLA&5 06.fNIMALBLADDER 4M 0 7.STEEL+INTERNAL LINING 0 95.UNKNOWN ❑ 99.O7tER S SECONDARY CONTAINMENT 0LSTEEL JJ 3.FIBERGLASS 06.EXTERIOR MEMBRANELIER 07.JACKETED 445 ❑ 90.NONE 0 95.UNKNOWN 099.OTBER(S ): 445a OVERFI.LPREVENTION 0 1.AUDIBLE&VLSUALALARMS U 2.HALLIFTUAT K3.FILLTUBE SHUT-OFF VALVE 457 0 4.TANKMEEiS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PRHVQdRON EQUIPMENT V: PRODUCT:/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 0 1.SBJGLE-WAILED 2.DOUBIE-WALLED 099.0THER 4e0 SYSTEM TYPE Lg I.PRESSURE 02.GRAVRY 3.CONVENOONAL SUCTION 4.SAFE SUCUON C23 CCR§2636(e)(3)1 4M PRIMARY CONTAINbII:NT Lj L STEEL Pq 4.FTBFRGIASS Lj E.FLEXIBLE 0 IO.RIGID PLAsrIC 4M 0 90.NONE 0 95.UNKNOWN 099.OTHER(Spaify): 469i SECONDARY CONTAINI� 0 LSTEEL W 4.FIBERGLASS S.FLEXIBLE 0 !0.RIGIDPLASTIC 4646 0 9o.NONE 0 95.UNKNOWN 0 99.OTFER(E � ): 0600 P/PIN(i/TURBINE CONtAtNMENT StJMPT'YPE 1.SINGLEWALL 2.DOUBIEWAW 090.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RLSER/FILL PIPE PIPING CONSTRUCPION- VENT PRIMARY CONTAINMENT L SIE¢ 4.FIBERGLASS I0.RIOID PLASTIC 0 90.NONE 0 99.OrImR(Speci>y) 4M' 4Mcl VENT SECONI. , ..NfA1NMENC 1.STIR¢ 4.FNBERGIASB ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Spee()() 464f a464 VR"U?AARY CONTAIAENT ❑ I.STEEL 4.FIRE IO.RIGID PLASTIC ❑ 40.NONE 099.OTHER(Spec 46ig 464 I VRSECONDARY CONTAINMENT I] 1.SUL 4,FIBERGi-A 0 10.RIGIDPLASTIC Sf 90.NONE [199.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE I.SINGLEWALL rl 2.DOUBLE WALL 90.NONE 4641 RISER PRIMARY CONTAINMENT P L STEEL. u4.FIBERGLASS U 10.RIGID PLASTIC RU 90.NONE U 99.OTHER(Specify) 464 il RISER SECONDAAV C6NfA1NMEM ❑ I.STEEL 4"FIBERGLASS IO.RIGID P[ASfIC 90.NONE 99.OTHER ISp cif§) 46/t 46/k1 FILL COMPONENTS INSTALLED 03I.SPHS.BUCKET 3.STRIKFRPLATEnIOITOMPROTECTOR 4.C5NrAINMENTSUMP 451a< VILUNDERDL%WASERCONTAINMENT.(UDC). - CONSTRUCTION TYPE 1.SINGLE WALL 0 2 DOUBLE WALL 0 3.NO DISPENSERS 0 90.NONE 4694 CONSFRucrION b1AiER1AI. I.STEEL 4.P3BERGLASS ❑ l0.MMPLASDC 0 99.0THER(Speciry) 469bc VIII. CORROSION-PROTECTION STEEL COMPONENT PROTECTION 02.SACRIFICIAL ANODES) 04.IMPRESSED CURRENT Qk 6.ISOLATION 44a DL APPLICANT SIGNATURE CERTH7ICATIOIN: I eertlfy that Wlt ST system is compatible with the hazardous substance stored and that the information Provided herein Is true,accurate, and in wBb W mquiresuents. 9l0. APPLICDATE APPLICANT N;A;vE(PrwQ 417' APPLICANTTME Rev.(122007) UPCF UST-B-112