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0IIFIED PROGRAM CONSOLIDATED F UNDERGROUND STORAGE TANK N� I 1 Ito )OPERATING PERMIT APPLICATION-TANK INFORMATION(one form )TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this sect' and Sections 1,I1,III,IV,and IX below) Os ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT [ZS.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) 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As 3 A BUSINESS SITE ADDRESS 103 1 CITY 104 IL TANK"DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TA K CONFIGURATION: THIS TANK IS 434 1.A STAND-ALONE TANK t o 3 7D A fj g,✓1/� �S ❑2.ONE 1N A COMPARTMENTED UNIT. r vtrP�'�'+P7 Complete one page for each compartment in the unit. DATE USTSYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 f l L>4C3 ©RJB :ITT.TANK-USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ ]b.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑, a.REGULAR UNLEADED ❑ 1 c.MIDGRADE UNLEADED ❑ 1 b.PREMIUM UNLEADED 440 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b ITANK CCNSTRUCTIfllai '" '. TYPE OF TANK ❑ 1.SINGLE WALL Ot 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNALLINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL F3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 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,/W WIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED M 2.DOUBLE-WALLED [:199.OTHER 460 SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION e4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL V9 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 5.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE OF 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VL VENT VAPO RECOVERYOM)''AND RISER4FIL`I.-PIPE PIPING CaONST3tUC ON VENT PRIMARY CONTAINMENT 10 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464g] VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE Q.1.SINGLE WALL ❑ 2.DOUBLE WALL 90.NONE 464i RISER PRIMARY CONTAINMENT 1& 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4641 464j] RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC 1190.NONE ❑ 99.OTHER(Specify) 464k 4640 FILL COMPONENTS INSTALLED 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451a-c .-UNDER DISPENSER CONTAIN ENT(UDC) CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90. N-:- 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 f' 448. VL APPLICANT.SIGNATURE ` CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information providio herein is true,accurate, 1-1 and in full compliance with legal requirements. ' F� � azo. AP IC T SIGNDATE A E L CANT NAME(print) 471 APPLICANT TITLE I 472. J ':SS' - r L 5 UPCF UST-B-1/2 Rev.(12/2007)