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UNIFIED PROGRAM CONSOLIDATED FORM �(� l� UNDERGROUND STORAGE TANK ( OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) J TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b I. 'FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 It5fc .k. ^i'--�'k- ..(T�� ///lY10 BUSINESS SITE ADDRESS 103 1 CITY IL TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 1.A STAND-ALONE TANK 2.ONE IN A COMPARTMENTED UNIT. N v Comelate one page for each compuftem in the urrit. DATE UST SYSTEM INSTALLED 435 TANK CAP CITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 0 r7 III.'TANK`USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 M 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(preludes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC$25281. 5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL J9 9.OTHER PETROLEUM (Specify): 71%Tw - ar 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV TANK CONSTRUCTION . TYPE OF TANK $ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN .OTHER($ ): _c.r,+C, u 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION 1.SINGLE-WALLED ❑2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 02636(ax3)I 458 PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT M 1.STEEL ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 90.NONE ❑ 95.UNKNOWN -a 99.OTHER(Specify): C"q" 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 4644 V1.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION_ VENT PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT 1.STEEL El 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ I.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 90.NONE 464L RISER PRIMARY CONTAINMENT I.STEEL 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j 464'I RISER SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 1 90.NONE 0 99.OTHER(Specify) 464k 464kI FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATEBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 454-c VII.UNDER DISPENSER CONTAINMENT.(UDC) CONSTRUCTION TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b-c VIII._CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT 6.ISOLATION 448• IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this US mpatible with the hazardous substance stored and that the information provided herein is true,accurate, and in full co ance with leeal requirements. APPLICANT SIGNATURE DATE t'p 470• APPLICANT NAME(print) t 471' APPLICANT TITLE 472.UPCF UST-B-1/2 Rev.(12/2007)