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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(oner«m" usin TYPE OF ACTION (C3tock one item only. Foran UST pemlaoeo ciasm or mmoval,eampkoe o*Ibis sect-and Sections L q III,I;and IX below) 430 ❑ 1.NEW PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 0 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a DATE EXIS WG UST DISCOVERED: 4Mb L-FACQ. FY II�TFRMTION- FACKM W#(Agency Use Only) ' BUSHeM NAME(Sa=as FACU11 Y NAME or DBA-Doing Business As) 3 WRTSgum MMINESS SITE ADDRESS Cny 104 LZ IL-TANK ON TANK ID#- %oso 7 Ct1% 43 TANK MANUFACIURER 4D TAW CONt:[ci<Ie nOw THm TANx is 434 ❑1.A srAND-M ora;TANK 3QQoo 8duo74 O ,82.4314EINA omeAzTsmnDuNIT. u.a forea3 :tl�eamt DAIT SYSTEM Bbl I Iv'�I T � O IN 4 NUMBER OF COMPARTMENTS IN THE UNIT 4n (o ��TA1+iI��iSE_AND;:C011� -: _ TANK USE la 1/OrTOR VEHICLE F[tEI.ING 13IIt MARINA FUELING 13 !c.AVIATRIN FUE,INti 439 ❑3.CHERUCAL PRODUCT STORAGE ❑4.HA7ARDOtIS WASTE(Iod"m Dsipa) ❑5.EMERGENCY GENERATOR FUEL IISC 12S281S(c)] ❑6.OTHER GENERATORFUEL ❑95.UNKNOWN ❑99.OTHER(Specify). 439a CONTENTS PET xotEux- ❑ la REGULAR UNLEADED ❑ la MIDGRALIE UNLEADED ® W PREMIUM UNLEADED 440 ❑3.DIESEL ❑S.JET FUEL ❑6.AVIATION GAS ❑8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM 440& MON-PETROLEUM:❑7.USED OIL ❑ 10.ETHANOL ❑ 1 I.OTHER NON-PETROLEUM ): 440b IV-TANK-CO HCTIQN TYPE OF TANK ❑ 1.SINGLE WALL 2.DOUBLE WALL 095.UNICIJOR+N 443 PRBIARY CONTARDMENI' ❑ 1.STEN. 3.FIBERGLASS ❑6.INTERNAL BLADDER 444 7.STEEL+INTERNAL LINING ❑95.UNKNOWN ❑99.OTHER (S 444a SECONDARY CONITAIVMENr 1.STEEL C1 I FIBERGLASS ❑d EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 90.NONE ❑ 95.UNKNOWN ❑99.OTHER . ): 445a OVERFILL PREVENTION 1.AUDIBLE A VISUAL ALARMS 0 2 BALL FLOAT 3.FILL.TUBE SHUT-OFF VALVE 452 ❑4.TANL MEETS REQUIREMENTS FOR ERFWFiIDN FROM OVERFILL PREVENTION EQUIPMENT Y.-PRUDII�.1-I WAMP,MNU COMTRUCTION PIPING CONSTRUCTION ❑L sINGLE-WALLED 2 DO(IBLE-WAu ED 99.OTHER q6p SYSTEM TYPE IN I.PRESSURE L32.GRAVITY ❑3.CONVENTIONAL SUCTION E34.SAFE SUCTION f23 CCR 12636(ax3) 458 PRBtARY CON mowoi TNI E3 I.STEEL is 4.FIBERGLASS ❑8.FLEXIBLE 13 10.RIGID PLASTIC 464 + ° ❑90.NONE ❑95.UNZMVIN ❑"-omER(Spa m, 464a SECONDARY CONTAINMENT 0 1.STEEL, 4.FIBERGLASS ❑S FLEXIBLE 0 10.RIGID PLASTIC 460 ❑9Q NONE ❑95.UNKNOWN ❑99.0THER(Specift 464c PIPINGiTURBINE CONTAINOHENT SUMP TYPEL SIMILE WALL 0 2 DOUBLE WAIL 0 9o.NONE 4644 L ,VAFOR 8E�0 (YR)AtIDkBLS�R =FIEL-PTFE-PEkNG CUNS RUC.'1ZOI�F VENT PRIMARY CONTARNMENT U 1.STEEL 4.FIBEROLASS U 10.RIGIDPLASTIC 0 90.NONE U 99.0116R(specify) 464e 46x1 VENT SECONDARY CONTADMIENT 0 I.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC J9 90.NONE 0 99.OTHER(Specify) 464f 46411 VR PRIMARY C:ONTAR&I 0 1.STEEL 4.FIBERGLASS 13 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 4648 VR SEC ONDARY CONTAIINMEIYT ❑ I.STEEL 13 4.r ROLASS ❑ 10.RIGID PLASTIC JM 90.NONE 13 99.OTHER(Specify) 464h 46441 VENT PIPING TRANSITION SUMP TYPE I.SINGLE WALL El 2 DOUBLE WALL 11 90.NONE 4641 RISER PRIMARY CONTAINIAEN T I.STEEL 4.FIBERGL.(1SS U t0.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 4647 461-} RISER SECONDARY CONTAINbEEN' I.STEEL E3 4.FIBERGLASS 13 10.RIGID PLASTIC 13 9o.NONE 13 99.OTHER(Specify) 4644 464k1 FILL COIMPONENTS INSTALLED I.SPILL BUCKET ig 3.STRICBR PLATuBO Tom PROTEC OR 4.CONTADQMENT SUMP 451a-c Xi4 UNDER DISPEriSE CO1�kTAtIlYIY .(,DC} CONSiRUC WN TYPE L SINGLE WALL ❑2.DOUBLE WALL ❑3.NO DISPENSERS ❑90.NONE 469a tIDNS1RtC-T10N MATERIAL L SIFEL Q 4.FIBERGLASS E3 I0.RIGIDPLASM ❑99.OTHER(Specify) 469bc VIW CORRMON PROTECTION STEEL COMPONENTPROTBCTIDN 0 2.SACR*xIAL ANOMM ❑4.BMRESSED CURRENT ❑6.ISOLATION w 448. JX- AFMCANT S.411m©W. CERTIMCATION:I cerdfy dot d#UST ma wdble v&tie haardsm spm sdaal wild Ad the fidW=don sad in fd win provbled herela true,accurate, APPLICANT SIGNATURE DATE 470. MMICANT NAME(print) APPLICANT TITLE W r r M UPCF UST-8-1/2 Rev.(1=007)