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REGPIVED 'UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK JAN 0 6 2015 OPERATING PERMIT APPLICATION-TANK INFORMATION one form per us TYPEOFACIION (Check one item only. Form UST permanent closureorremoval,complete only this section end SeMioi �'n{ 430 ijjj❑ 1.NEW PERMIT 0'3.RENEWAL PERMIT ❑ S.CHANOEIf,Qjjf 6.TEMPORARY UST CLOSURE. TUSTPERMANENTCLOSURBONsm 8.USTREMOVAL DATE UST PERMANENTLY CLOSED: 430' DATE EKISTINO UST DISCOVERED: :/� 43116 \)� I. FACILITY INFORMATION 7 / FACILITY I D N(Agency Use Only) FA 4Qb5 LA I BUSINESS NAMBJ(S�me es FACILITYNAM6 DBA-Doing Business As) 3 C6/ G �$TL �! O / f / ! <f</1/�2/t s/r wsf/e� H X I/ ✓I �lwt b/uI� BUSINVS SITE ADDRES$� V p lea `g", ITY 1 f /`7e/i /le O,f se1/n IL TANK DESCRIPTION TANK IDN 033 TANK MANUFAC)URER 433 TANK CONFIGURATION:THIS TANK IS n4 A STAND-ALONETANK 2.ONB M A COMPARTMEM'ED VNTT. uA�t OOLO A ff/W Com eroeca fore diw Im ee.1L DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 IIL TANK USE AND CONTENTS TANK USE Q le:MOTOR VEHICLE FUELING Q Ib.MARINA FUELING ❑ la AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCTSTORAGE )K4.HAZARDOUS WASTE BndJ Lbd Oil) ❑ S.EMERGENCY GENERATOR FUELIBSC I35121.5(01 ❑ 6.OTHER GENERATOR FUEL Q 95.UNKNOWN ❑99.OTHER(Specify): 439. CONTENTS PETROLEUM: ❑ Is.REGULAR UNLEADED ❑ I..MIDGRADEUNLF.ADED ❑ Ib.PREMIUM UNLEADED 440 ❑3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION OAS ❑ S.PETKOLEUM BLEND FUEL 9.OTHER PETROLEUM S i :u OIAf (L 440. NON-PESROLEUM:ll!L 7.USED OIL ❑ 10.ETHANOL ❑ I1.OTHER NON-PETROLEUM(Specify): '1466 IV. TANK CONSTRUCTION TYPEOFTANK ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL ❑3.FISERGLASS ❑ 6.INTERNAL BLADDER H4 Q 7.STEEL+RIERNALLINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): We SECONDARY CONTANMET9T ❑ LSTEEL 03.FIBERGLASS Q 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED NS ❑90.NONE ❑95.UNKNOWN ❑99.OTHER S i 445. OVERFILL PREVENTION D 1.AUDIBLE R VISUAL ALARMS U 2.BALL FLOAT 3.FILL TUB SHUT-OFF VALVE 452 ❑4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 01.8INOLE-WALLED 02.DOUBLE-WALLED 099.OTHER 460 SYSTEM TYPE ❑ LPRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION C23 CCR 13636(.)(3) 459 PRIMARY CONTAINMENT Q 1.STEEL ❑4.FIBERGLASS ❑ S.FLEXIBLE ❑ I0,RIGID PLASTIC 464 ❑90.NONE ❑ 95.UNKNOWN 112?- 99.OTHER(Spmi%): 464. SECONDARY CONTAINMENT LSTEEL ❑4.FIBERGLASS El 8,FLEXIBLE ❑ IO,RIGID PLASTIC 4646 4 [190.NONE ❑95.UNKNOWN ❑ 99.OTHER(Specify): __ 46tc PIPINGRURBINECONTAINMENTSUMP TYPE ❑ I.SNOLEWALL ❑ 2.DOUBLE WALE. ❑ 90.NONE 4Wd VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION . VENT PRIMARY CONTAINMENT L1 I.STEEL L1 4.1`I13ERGLA53 10.RIGID PLASTIC LJ 90.NONE 99.OT'HER(Spec)Sy) 46M 461e1 VENT SECONDARY CONTANMENT I.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC Ll 90.NONE.El 99.MER(Specify) 464E 4wn VR PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC C1 90.NONE 99.OTHER(SWily) wit 4MR1 VR SECONDARY CONTAINMENT I.STEEL ❑ 4.FIBERGLASS ❑ ILLRIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spwify) 464h 4Mhl VENT PIPING TRANSITION SUMP TYPE I.SINGLEWALL 71 2.DOUBLEWALL El 90.NONE 4641. RISER PRIMARY CONTAINMENT HU 1.STEEL LJ 4.FIBERGLASS U 10.RIGID PLASTIC ❑ 90.NONE U 99.OTHER(Specify) 4641 1647 RISER SECONDARY CONTAINMENT LSTEEL 0 4.FIBEROLASS Q 10.RIGID PLASTIC El %.NONE 99.OTHER(Spedly) 4 k 464k1 FILL COMPONENTS INSTALLED ❑ L.SPILL BUCKET 0 3.STRIKER PLATFIBOTTOM PROTECTOR 0 4.00 TAINMEFJr SUMP 451e< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ I.SINGLEWALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATERIAL ❑ 1.STEEL ❑4.FIBERGLASS ❑ 10.RIOID PLASTIC L3 99-OTHER(Specify) 4696.0 VUL CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT ❑6.ISOLATION 441. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST stem is com a with the hazardous substance stored and that the information provided hereto Is true,stearate, and in f fl once r vl Inti. APPLICANTSIONA - DATE / .4� 4M APPLICANT NAME(ori001' APRLICANTTITI.15 473- UPCF UST-B-12 Rev.(12/2007)