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d UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form «UST) 'TYPE OF ACTION (Check one item only. For en UST permanent closure m mmovai,complete only this section and Sections 1,II,Ili,N,and IX below) 43D ].NEW PERMIT ® 3 RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE. 7.UST PERMANENTCLOSURB ONSTIE B.UST REMOVAL °eb DATE UST PERMANENTLY CLOSED: °10s DATEEXISTINGUSTDISCOVERED: � ,�{ L FACILITY INFORMATION J1� 0 3 I IS t6 FACILITY ID M(Ag«tty Ute Only) ) - - 1 oUo 3 �t , �BfUSINESS NAME(Sameas FACILITYNAME rDBA-Doin3Business As) _ [..a1 csa -S7<<-f� O s i < w < {< r{C 4.Si4•�dS Ia yE7!9 �/ 4�i <♦ /w<•Fui� BUSINESS SITE ADDRES m3 CITY IL TANK DESCRIPTION TANK IDM 431 TANK MANUFACTURER 431 TANK CoNptoummow:TTBSTANxis aro AsrAND-ALONETANK 2.ONE M A COMPARTMENTED UNIT. 4<w�fw/tr 4411AO Co leb.ne Por e,.h mm saran in6w emit DATE UST SYSTEM INSTALLED 411 TANK CAP�j+CTTY iNGAU.ONS 436 NUMBER OF COMPARTMENTS MTHE UNIT 03J w `TANK USE AND CONTENTS TANKUSE ❑ Ie.MOTORVEHICLEFI ELING ❑ I6.MARINA FUELING ❑ 1.AVIATIONiUELINO 439 ❑ 3.CHEMICAL PRODUCTSTORAGE K4.HAZARDOUS WASTEUnduderl Oil) ❑ S.EMERGENCYGENERATOR FUEL[HSC 4351).5(.)] 439. ❑ 6.OTHER GENERATOR FUEL ❑95.UNKNOWN ❑ 99.O7HER(Specify): Mo CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED ❑ Io.MIDORADS UNLEADED ❑ I6.PREMIUM UNLEADED ❑3.DIESEL ❑S.MT FUEL ❑ 6.AVIATION OAS A4/N /4. aoa [I &PETROLEUM BLEND FUEL 9.OTHER PETROLEUM i NON-PETROLEUMJ&I.USED OIL 10.ETHANOL Mob ❑ Il,OTHERNON-PETROL.EUM S IV. TANK CONSTRUCTION TYPE OF TANK 13I.SINOLEWALL Ll3.DOUBLEWALL El95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNALE LADDER ❑7.STEEL+INTERNALLININO [1'95.UNKNOWN E3 99.OTHMt SECONDARY CONTAINMENT ❑ ].STEM ❑3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ t�� HS 1-190.NONE ❑ 95.UNKNOWN ❑99.OTHER 3 i r C.'V45s OVERFILL PREVENTION U L.AUDIBLBS:VISUALALARMS iBALL FLOATu 3.jquiub8snul'-OFFVALYff45z ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V, PRODUCT/WASTE PIPING CONSTRUCTION PIPMOCONSTRUCTION ❑I.SMGLE-WAL.ED ❑1DOUBLE.WALLED ❑99.0TIm °m SYSTEM TYPE ❑ I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION In CCR 3196(4X3)1 45a PRIMARY CONTAINMENT ❑ I.31hez ❑4.FiBEROLA3S ❑B.FLEXIBLE ❑ 10.RIGID PLASTIC 469 ❑90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S Ty): 4&lb SECONDARYCONTAIMdENT 1.STEEL ❑ 4.FIBERGLASS ❑S.FLEXIBLE ❑ 10,RIGID PLASTIC 4616 ❑90.NONE ❑95.UNKNOWN [199.OTHERS ify): 461. o PIPMGRURBINE CONTAINMENT SUMP TYPE ❑ LSINOLBWALL ❑]•DOUBLE WALL El 90.NONE 164d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION . VENTPRIMARY CONTAINMENT ❑ I.STEEL 4.FISEROLASS IO.RWIDPLASTIC U W.NONH 99.OTHER(Spediy) 4U 464.1 VENTSECONDARY CONTAINMENT El 1.STEEL ❑4.FIBERGLASS 0 ID.RIGID PLASTIC ❑ 90.NONB,0 99.6THER(Spccify) 4616 4wn YR PRIMARY CONTAINMENT ❑ 1.STEEL 4.FI BERGIASS 10.RIGID FI.ASTIC 90.NONE 99.6TNER(Specify) 4641 461 1 VR SECONDARY CONTAMMENT ❑ I.STEEL 0 4.FIBERGLASS 0 ILL RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spe6fy) 46461 101 VENT PIPING TRANSITION SUMP TYPE I.SINGLEWALL 2.DOUBLE WALL 90.NONE 4641. RISERPRIMARYCONTAINMENT HU 1. TEFL 4.FIBERGLASS LI 10.RIGID PLASTIC U W.NONE D 99.OTHER(Spedfy) 4644 464'1 RISER!ECONDARY COW:i i NI' LSTEEL 4.DBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(SPWW 461 461 n FILL COMPONENTS INSTALLED I.SPILLBUCKET U 3.STRIKEIt PLATVBOTTOM PROTECTOR 4.CONTAMMENISUMP 451. VD.UNDER DISPENSER CONTAINMENT(GDC) CONSTRUCTION TYPE ❑ 1.SINGLEWALL ❑ 2.DOUBLE WALL ❑ 3.NODTSPENSE. ❑ 90.NONE 469. CONSTRUCTION MATERIAL ❑ 1.STEEL [14.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER ) 4696. VIII. CORROSION PROTECTION STEELCOMPONENTPROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑6.ISOLATION 441 IX. APPLICANT SIGNATURE CERTIFICATION: I certiry that this UST system Is compatible with the hazardous substance stored and that the Information provided herein 6 true,accurate, and to(LIT com e Ora APPLICANT SIGNA DATE APPLICANT NAME(ndai411' APPLICANTTITLE b " 4n' alfid G//2/r�L� UPCF UST-B-112 Rev.(12/1007)