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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One corm per UST) TYPE OF ACTION (Check one item only. For as UST petmaneot cloeltte or removal. on[y this section and Sections 1,II,III,IV,and IX below) 436 ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE Q 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ t BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business AS) 3 �S BUSINESS SITE ADDRESS 1 U l CITY los _IL.TANK P�SCRTPI'ION.' TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 1 1 Ql �1.A E I NA COMPB TANK rW1 r,,h/FJ- ❑2.ONE IN A C060'ARTAtETifED UNIT. sae Ewcmb ladamda. DATE UST SYSTEM ALLED 435 TANLCAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 UL T-ANKUSSEAND COr1TEN1"S TANK USE jiff la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ Ic.AVIATION FUELING 4 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(ladida Und OR) ❑S. R FUEL[mc Iamis(a)1 ❑6.OTHER GENERATOR FUEL 93. WN rl ')TYLER(Spow: 439a CONTENTS PETROLEUM: Ia.REGULAR UNLEADED E3 le.MIDGRADE UNLEADED REMIUM UNLEADED- 440 3.DIESEL ❑S.JET FUEL, Ll 6.AVIATION GAS ❑S.PETROLEUM BLEND FUEL ❑9.OTHER PETROLEUM 440a NON-PETROLEUM:❑7.1 OIL ❑ t0.ETHANOL 13 11.OTIIFA NON-PELROIE()M 4 Iy TANKFiawcnw. . TYPE OF TANK 0 1.SIIQ(AE WALL iff LpOUBEE WALL 93.UNKNOWN 44 PRIMARY CONTAINMENT 131.STEEL 6.INTERNAL BLADDER 444 Cl7.STEEL+ E3 95.UNKNOWN 99.OTHER 5 444 SECONDARY CONTAINMENT 1.STEEL 3.FIBERGLASS ❑b.fiXTER10R MEMBRANE LINEA 7.JACKETED 445 IN 1390.NONE 93.UNKNOWN ❑99.OTHER 445a OVERFILL PREVENTION 1.AUDIBLE A VISUAL ALARMS L BALL FLOAT • 3.FILL TUBE SHUT-OFF VALVE 45L C34.7AINK MEETS FOR EXEMPTION FROMOVERFILL PREVENTION EQUIPMENT V:`PRO T WASTE PIPING CONSTRUCTION . PIPING CONSTRUCTION 1.SINGLE-WALLED DOUBLE-WALLED 99.OTHBR 460 SYSTEM TYPE 1.PRESSURE GRAVITY 0 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION ED CTA¢ 436 PRIMARY CONTAmuff ❑ 1.STEEL F4,TEBEItGLASS 0 8.FLEXIBLE 0 10.RIGID PLASTIC 464 ❑90.NONE f4. .t INKNOWN ❑99. ): 464. SECONDARY CONTAINMENT L STEEL FIBERGLASS L Fr XIII rt 10.RIGID PLASTIC❑90.NONE .UNKNOWN ❑".OTHER( ): 464c PIPINGrrURBINE CONTAINM NT SUMP TYPE INGLE WALL Z DOUBLE WALL 9a NONE L YFdV';VAPOR i*- AND RRf':IILT..PIPE PRIG CAl9TRUCTION VENT PRIMARY CONTAINMENT 1. FIBERGLASS la RIGID PLASTIC 9a NONE 99.OTHER(Spadly) 464e 464e! VENT SECONDARY CONTAINMENT L.STEEL. FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTITER(SPedtY) 46411 VR PRIMARY CONTAINMENT 0 1.STE jW4.FIBERGLASS 10.RIGID PLAST IG13 90.NONE 13 W OTHER(SpW&) 464S1 I VR SECONDARY CONTAINMENT ❑ 1.STEEL FLBEROLASS 10.RIGID PLASM 90.NONE 99.OTHBR(Spadb) 464bl VENT PIPING TRANSITION SUMP TYPE 1.SING[E DOUBLE WALL 90. NE W�'• 0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464J RISER PRIMARY CONTAINMENT !.STEEL FIBERGLASS 1641 I.STEEL FIBERGLASS 10.RIGID PLASTIC NONE 99.OTHER(Spud*) 464k RISER SECONDARY CONTAINMENT 1 LL FILL COMPONENTS INSTAED 1.SPILL BUCKET 3.STRIKER PLATEIBO TtOM PROTECTOR 4.CONTAINMENT SUMP ac VII.UNDER"D COSiTAIl . CONSTRUCTION TYPE 1.sINGt E W t DOUBLE WALL 3.NO DISPENSERS 90.NONE 99.OTTtER(S CONSTRUCTSON MATERIAL 1.STEEL FIBERGLASS 10.RKIID PLASTIC "'m CORROSION:PRt)TEC1'i4�i STEEL COMPONENT PROTECTION 13 L SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT 6 ISOLATION D AMJCANTSIGN,ATURSI: CERTWWAT[ON:I earth,daft tics UST"W" is esupattbIs wYY the iasacdc"$Nbdmaee stared sad that iafortoatloa provided herds 4 tru0.aeeurste, SPAIN-Am emwvlla_� mmulmameas r 4 APPLICANT SIGNATU DATE 4nAPPLICANT N (print) 4n' APPLICANT TITLE Rev.(12rA n UpCrW:&: 112