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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UsT) 17MOF ACTION (Check one item only. Foran UST pamanew clow=or removal,complete only this section and Sections I,It III,IV,and TX below) 430 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 3.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430" DATE EXISTDIG UST DISCOVERED: 430b V FACILM Il�iFORAIATION FACILITY ID#(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADD S 103 CITY 104 /-� ml IL TANK DESCRIPTION TANK ID# 432 1 TANK MANUFACTURER 49 TANK CONFIGURATION:THIS TANK iS 434 ❑1.A STAND-ALONE TANK /P V 2. IN ONE A COM ( Q DCS �v�o Ct ,�i1J,��i/- ❑ am a�� DA UST INSTALLED 43s TANK CAPACITY 1N GALLONS 436 NUMBCBSER OF COMPARTMENTS istIN THE UNIT 437 TAIL£VWAND CONTENTS . TANK USE la MOTOR VEHICLE FUELING ❑ lb.MARBYA FUE1240 ❑ le AVIATION FUELING 439 ❑3.CH6MACAL PRODUCT STORAGE 134.HAZARDOUS WASTE 0mdmd=Umd(m (3 S.EMERGENCY GENERATOR PURL(ESC#23281.(.)1 ❑6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN C3 99.OTHER( 439a CONTENTSPETROLEUM- ® 1&REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMRIM UNLEADED 440 ❑3.DIESEL ❑ S.JEf FUEL ❑6.AVIATION OAS ❑8.PETROLEUM BLEND FUEL ❑9.OTHER PETROLEUM 440a NON-PETROLEUM 7.USED OIL 0 10.ETHAN(M. 11.OTHER ION-PETR LEU&ftEft 4406 V TANK�CONS1RiiGTIQN ' TYPH OF TANKEj 1.SINGLE WALL 2 DOUBLE WALL 9S.UNKNOWN 443 PRIMARY COWAR4 4M U 1.STEEL Iff 3.FIBERGLASS U 6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING Q9S.UNKNOWN ❑99.OTHER S 4441 SECONDARYCONTAINMENT i.STEEL 3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER 7.JACKETED 445 ❑90.NONE 93.RJPB040WN 99.OTilER 4451 OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2 BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452 ❑4.TANK MEETS FOR EUIPTION FROM OVERFILL PREVENTION EQUIPMENT V PROI>UC1`lR�lI41T PILING BONS 'RIICTION PIPING CONSTRUCTION 1.SINGLE-WALLED 2.DOUBLE-WALLED ".OTHER 46D SYSTEM TYPE 1.PRESSURE 0 2 GRAVITY Ej 3.CONVENTIONAL SUCTION 0 4.&4FESUCnONp3ajtj263) 458 PRIMARY CONTAINMENT I.STEEL 0 4.FIBERGLASS E3 1R FLEXIBLE 0 10.RIGID PLASTIC 464 ❑90.NONE ❑9S.UNKNOWN ❑99. ' r 4641 SECONDARY CONTAINMENT El 1.STEEL A 4.FIBERGLASS E3 L FLEXIBLE 10.RIGID PLASTIC 464b ❑90.NONE ❑95.UNKNOWN ❑99.GTHER( ): 464c PIP04GITURBINE CONTAINMENT SUMP TYPE 13 L SINGLE WALL 2.DOUBLE WALL 0 90.NONE 4641 VAPOR.RECOVERY(YID ASID RL I RIId,EIi!E.PIRING G'011TSTRUCTIOl i VENT PRIMARY CONTAINMENT I.STEEL E3 4.FIBERGLASS 0 10.MUM PLASTIC U 90.NONE U 99.OTHER(Specify) 4641' 46141 VENT SECONDARY CONTAINMENT I.sSTEELEl 4.FIBERGLASS E3 10.RIGID PLASTIC 90.NONE 99.07HER(Spec*) 461 464n VR PRIMARY CONTAINMENT L STEM 13 4.FIBERGLASS Ll 10.RIGID PLASTIC 0 90.NONE 0 ".OTHER(Specify) 464j; g VR SECONDARY CONTAINMENT I.STEEL E3 4.FIBERGLASS 13 10.RIGID PLASTIC 90.NONE13 ".OTHER(Specify) 46tb 4661 VENT PIPING TRANSITION SUmFWW-j0 L SINGLE WALL Q 2 DOUBLE WALL m 90.NONE 464L RISER PRIMARY CONTARGIENT 1.MiE. U 4.FIBERGLASS Ll 10.RIGIDPLASTIC 0 90.NONE El 99.OTHER(Speci&) 464) 4601 RISER SECONDARY CONTADMENT L STEEL 13 4.FIBERGLASS Ej 10.R1GIDPLASTIC 0 90.NONE 13 99 OTHER(Specify) 464k 464k1 FILL COAlPONEMS ENSIALIED 1.SPILL BUCKET 3.STRIKER PLATE1B01TOM PROTECTOR 4.CONTAINMENT SUMP 451" CONSTRUCT#DN TYPE 1.S94GLE WALL ❑2 DOUBLE WALL ❑3.NO DISFk4SERS 13 90.NONE CONSTRUCTION MATERIAL 0 1.STM Q 4.FIBERGLASS IL 10.RIGID PLASTIC El 99.OTHER vm IORQ6ItkI-PR(ITEC'fION STEEL COMPONENT PROTECTION ❑2 SACRmiaAL ANODES) [34.IMPRESSED CURRENT 0 6.ISOLATION ,. °' IX. 4RPPLICAN'1"SIGNAThItL, � �x� CB,RTWCATION:I try That frit I r g r 4s apWbie wltk At:bmrdoa tnbtan4m sated and that dw information provided � accurate, and In fda .0 \:.. APPLIC SIC DATE m' 470. e, 471. APPL APPLICANT NAME OAK) ICANT TITLE naui 472 0 r+ UPCF UST-5-uz