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��r f la✓Z UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) 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 j9 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:.'FACIITFY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME Same as FACILITY NAME or DBA-Doing Business As) 3 BUSINESS SITE ADDRESS O 103 CITY 104 IL TANKDESCRIPTION TANK TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS - 434 ��ID�o-7 n itS („32 ❑ .A STAND-ALONE TANK JlJ ` 11[! A ONE IN A COMPARTMENTED UNIT «e one foreach eaR in the mdL DATE UST SYSTEM INSTALLED 435 TANK C ACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 C) O d III:TANK USE AND CONTENTS TANK USE la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ !c.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(tndvdes 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 ❑ lc.MIDGRADE UNLEADED A lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM S 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PFMOLEUM(Speci 440b Iv; TAN �ON�STItICTION7777777 w TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY.CONTAINMENT 2k 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN 1399.OTHER (Specify): 444a SECONDARY CONTAINMENT [11.STEEL K3.FIBERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS 0 2.BALL FLOAT ^3.FILL TUBE SHUT-OFF VALVE 452 ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT �. PRt3Di7CT�wAS PIPIl�IG,coNs�TR�CTiOrr . `. PIPING CONSTRUCTION ❑1.SINGLE-WALLED 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE C&1.PRESSURE ❑ 2.GRAVITY ❑3.CONVENTIONAL SUCTION ❑4.SAFE SUCTION[23 CCR§2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 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.RIGIDPLASTIC 464b ❑ 90.NONE 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE I.SINGLE WALL ❑2.DOUBLE WALL ❑ 90.NONE 4&d VI`VENT,vAPQR`_RELwOER�Ems)Ate}RISER f Vii:PIPE.PIPIN CONSRiTC' © F . VENT PRIMARY CONTAINMENT ❑ 1.STEEL PQ 4.FIBERGLASS El 10.RIGID PLASTIC U 90.NONEU'99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464E 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL 5 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑90.NONE 0 99.OTHER(Specify) 4648 I VR SECONDARY CONTAINMENT ❑ 1.STEEL jo4.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 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT U 1.STEEL Ll 4.FIBERGLASS 10.RIGIDPLASTIC 90.NONE 0 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED M I.SPILL BUCKET 0 3.STRIKER PLATEBOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 451ac "�tII..I'IlVDER'I?ISPF�NSEI��QL�TAINMENT(UI)C);';. . ., CONSTRUCTION TYPE 1.SINGLE WALL ❑2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑90.NONE v-, 469a CONSTRUCTION MATERIAL 1.STEEL .FIBERGLASS ❑ 10.RIGIDPLASTIC ❑99.OTHER(Specify) 469bc VIIL .CORROSION-T'RE"I'IOt STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑4.IMPRESSED CURRENT jo 6.ISOLATION 448. DL'APPLICANT SIGNATFJRE CERTIFICATION:I certify at this AST systemp is compatible with the hazardous substance stored and that the information provided herein i`` accurate, andWall com a widVezal requirements. APPLICANT SIGNATU DATE / ! f� r470• 0 ( � APPLICANT NAME(p i / a71. APPLICANT TITLE C y 7_7 472 I� y'G t✓' UPCF UST-B-112 Rev.(12/2007)