AMERICAN NATIONAL BANK &
)
TRUST CO . - LAND TRUST 124234-06,
)
Petitioner,
)
V.
ILLINOIS ENVIRONMENTAL
PROTECTION AGENCY,
Respondent.
Dorothy M . Gunn, Clerk
Illinois Pollution Control Board
James R
. Thompson Center
100 West Randolph Street
Suite 11-500
Chicago, IL 60601
RECEIVED
BEFORE THE POLLUTION CONTROL BOARD
CLERK'S OFFICE
OF THE STATE OF ILLINOIS
JUN 1 6 2006
Pollution
STATE OF
Control
ILLINOISBoard
PCB No. 06- j qr
(LUST Appeal - Ninety Day Extension)
NOTICE
Thomas A . Brecheisen, P.E.
Kowalenko & Bilotti, Inc .
118 North Peoria Street, Suite 5 North
Chicago, IL 60607
PLEASE TAKE NOTICE that I have today filed
with the office of the Clerk of the Pollution
Control Board a REQUEST FOR NINETY DAY EXTENSION
OF APPEAL PERIOD, copies of which
are herewith served upon you .
Respectfully submitted,
ILLINOIS ENVIRONMENTAL PROTECTION AGENCY,
Respondent
Melanie A . Jarvis
Assistant Counsel
Special Assistant Attorney General
Division of Legal Counsel
1021 North Grand Avenue, East
P.O. Box 19276
Springfield, Illinois 62794-9276
217/782-5544
217/782-9143 (TDD)
Dated: June 14, 2006
CERTIFICATE OF SERVICE
I, the undersigned attorney at law, hereby certify that on June 14, 2006, I served true and
correct copies of a REQUEST FOR NINETY DAY EXTENSION OF APPEAL PERIOD, by
placing true and correct copies in properly sealed and addressed envelopes and by depositing
said sealed envelopes in a U .S
. mail drop box located within Springfield, Illinois, with sufficient
First Class postage affixed thereto, upon the following named persons
:
Dorothy M
. Gunn, Clerk
Thomas A
. Brecheisen, P.E.
Illinois Pollution Control Board
Kowalenko & Bilotti, Inc .
James R. Thompson Center
118 North Peoria Street, Suite 5 North
100 West Randolph Street
Chicago, IL 60607
Suite 11-500
Chicago, IL 60601
ILLINOIS ENVIRONMENTAL PROTECTION AGENCY,
Respondent
Melanie A . Jarvis
Assistant Counsel
Special Assistant Attorney General
Division of Legal Counsel
1021 North Grand Avenue, East
P.O
. Box 19276
Springfield, Illinois 62794-9276
217/782-5544
217/782-9143 (TDD)
REOUEST FOR NINETY DAY EXTENSION
OF APPEAL PERIOD
NOW COMES the Respondent, the Illinois Environmental Protection Agency ("Illinois
EPA"), by one of its attorneys, Melanie A
. Jarvis, Assistant Counsel and Special Assistant
Attorney General, and, pursuant to Section 40(a)(1) of the Illinois Environmental Protection Act
(415 ILCS 5/40(a)(1)) and 35 Ill . Adm
. Code 105 .208, hereby requests that the Illinois Pollution
Control Board ("Board") grant an extension of the thirty-five (35) day period for petitioning for a
hearing to September 19, 2006, or any other date not more than a total of one hundred twenty-
five (125) days from the date of service of the Illinois EPA's final decision
. In support thereof,
the Illinois EPA respectfully states as follows :
1 .
On May 15, 2006, the Illinois EPA issued a final decision to the Petitioner
.
(Exhibit A)
2.
On June 12, 2006, the Petitioner made a written request to the Illinois EPA for an
extension of time by which to file a petition for review, asking the Illinois EPA join in requesting
that the Board extend the thirty-five day period for filing a petition to ninety days
. Tracking
information from the Certified Mail number on the final decision indicates the final decision was
received on May 17, 2006 . (Exhibit B)
1
RECEIVED
CLERIC'S OFFICE
BEFORE THE POLLUTION CONTROL BOARD
OF THE STATE OF ILLINOIS
JUN 1 6 2006
AMERICAN NATIONAL BANK &
)
Pollution
STATE OF
Control
ILLINOISBoard
TRUST CO . -
LAND TRUST 124234-06, )
Petitioner,
) .
v.
)
PCB No . 06-
ILLINOIS ENVIRONMENTAL
)
(LUST Appea -Ninety Day Extension)
PROTECTION AGENCY,
)
Respondent . )
3 .
The additional time requested by the parties may eliminate the need for a hearing
in this matter or, in the alternative, allow the parties to identify issues and limit the scope
of any
hearing that may be necessary to resolve this matter
.
WHEREFORE, for the reasons stated above, the parties request that the Board,
in the
interest of administrative and judicial economy, grant this request for a ninety-day extension
of
the thirty-five day period for petitioning for a hearing.
Respectfully submitted,
ILLINOIS ENVIRONMENTAL PROTECTION AGENCY,
Respondent
Melanie A . Jarvis
Assistant Counsel
Special Assistant Attorney General
Division of Legal Counsel
1021 North Grand Avenue, East
P
.O
. Box 19276
Springfield, Illinois 62794-9276
217/782-5544
217/782-9143 (TDD)
Dated: June 14, 2006
This filing submitted on recycled paper.
2
June 12, 2006
Mr. William Ingersoll
Illinois Environmental Protection Agency
Division of Legal Counsel
1021 N
. Grand Avenue East
Springfield, Illinois 62794-9276
Re: LPC #0310515269
- Cook County
Cicero / Former Manufacturing Site
1910-2100 S
. 54' Avenue
LUST Incident Nos
. 992714 & 20040465
Dear Mr. Ingersoll
:
On behalf of the Owner of the above referenced facility, Kowalenko & Bilotti, Inc
. (K&B)
respectfully requests a 90-day extension to appeal the Agency's decision regarding an
application for reimbursement from the LUST fund
.
The attached May 15, 2006 IEPA Comment Letter (Letter) states that costs incurred prior to the
IEMA notification date of April 7, 2004 (IEMA No
. 20040465) were not reimbursed
. However,
in the IEPA-approved High Priority Corrective Action Plan & Budget, the IEPA approved costs
associated with corrective action pertaining to the original IEMA Incident No
. 992714
(December 9, 1999)
. K&B inquired why corrective action costs prior to April 7, 2004 were not
reimbursed
. The IEPA informed K&B that the IEPA-approved reimbursement was based on the
December 28, 2004 letter of eligibility from the OSFM, which pertained to IEMA No
. 20040465.
A copy of the OSFM Letter has been attached for your reference
. The IEPA informed K&B that
a separate letter from the OSFM, pertaining to IEMA No
. 992714, would be required for the
reimbursement of corrective action costs incurred prior to April 7, 2004
.
K&B contacted the OSFM and requested a letter that would meet the IEPA requirements
described above
. The OSFM informed K&B that they could not issue a letter cross referencing
the two incidents.
The OSFM informed K&B that the original IEMA, incident would be
associated with an additional $100,000 deductible because only one incident is allowable per
facility per calendar year
. At this point, K&B took time to consider any options
.
Finally, on June 9, 2006, K&B again contacted the OSFM office to petition that an additional
$100,000 deductible should not apply because the April 7, 2004 IEMA Incident No
. 20040465
was essentially a re-reporting of the original IEMA Incident No
. 992714
. The original IEMA
Incident Number was provided on the LUST Fund Eligibility and Deductible Application, which
has been attached for your reference
. K&B demonstrated to the OSFM that the IEPA had
118 North Peoria Street, Suite 5 North
1866 Sheridan Road, Suite 308
Chicago, Illinois 60607 U
.S .A .
Highland Pork, Illinois 60035 U
.S .R .
tel : 312-853-0500
tel : 847-433-4773
Fax : 312-853-0311
Fox: 847-579-4863
KOWALENKO & BILOTTI, INC
MANAGEMENT
Division
RECEIVED
of Legal Counsel
JUN 13 2006
Environmental Protection
Agency
Mr. William Ingersoll
June 12, 2006
KOWRENKO 5 IBIIOTTI, INC.
Page 2 of 2
MRNAGEMENT
ENGINEERING
ENVIRONMENT
LPC #0310515269
combined (and closed) the Incidents and approved corrective action costs dating to the original
IEMA notification date of December 9, 1999.
Upon understanding that K&B was simply
seeking an eligibility determination pertaining to the original IEMA Incident, and that K&B was
not asking the OSFM to combine and cross-reference the IEMA numbers, K&B was informed to
submit a LUST Fund Eligibility and Deductible Application using the information from the
original IEMA Incident No . 992714 .
Therefore, K&B respectfully requests a 90-day extension to appeal the Agency's decision
provided in the May 15, 2006 Letter . The request for the extension is based upon a
miscommunication between K&B and the OSFM. The 90-day extension is required to submit
the LUST Fund Eligibility and Deductible Application to the OSFM . Upon receipt of the
OSFM's written decision, K&B will forward the decision to the IEPA LUST Claims Unit and
seek reimbursement of the approved corrective action activities performed between December 9,
1999 and April 7, 2004
. K&B does not believe more than 90 days will be necessary to resolve
this matter.
K&B hopes that this information is sufficient to warrant the issuance of a 90-day extension for
this matter. Please do not hesitate to contact me at 312-853-0500 (ext
. 26) if you have any
questions or comments
. Thank you for your assistance with this matter and I look forward to
hearing from you.
Sincerely,
j AtrT44
n,,
I+ . 31M-,k,
.
.,t„
Thomas A. Brecheisen, P.E.
Attachments
cc:
Andres Schcolnik, American National Bank & Trust No . 124234-06
1021 NORTH GRAND AVENUE EAST, P .O . Box 19276, SPRINGFIELD, ILLINOIS 62794-9276 - ( 217) 782-3397
JAMES R . THOMPSON CENTER, 100 WEST RANDOLPH, SUITE 11-300, CHICAGO, IL 60601 -(312) 814-6026
ROD R . BLAGOJEVICH, GOVERNOR
DOUGLAS P . SCOTT, DIRECTOR
217/782-6762
CERTIFIED MAIL #
MAY 15 2006
7004 2510 0001 8593 1152
Andres Schcolnik
c/o ANSCO Real Estate Investments
2035 W. Giddings Street
Chicago, Illinois 60625
Re: LPC #0310515269 -- Cook County
Cicero/Former Manufacturing Site
1910-2100 South 54th Avenue
Leaking UST Incident No . 20040465
Leaking UST FISCAL FILE
Dear Mr. Schcolnik :
The Illinois Environmental Protection Agency has completed the review of your application for
payment from the Underground Storage Tank Fund for the above-referenced Leaking UST
incident pursuant to Section 57.8(a) of the Illinois Environmental Protection Act (Act), and 35
Ill. Adm
. Code 732, Subpart F. This information is dated November 3, 2005 and was received
by the Agency on November 7, 2005. The application for payment covers the period from
December 7, 1999 to November 4, 2005 . The amount requested is $195,365.84.
The deductible amount for this claim is $100,000 .00. $18,966 .39 was previously deducted from
the billing submittal received by the Agency on November 7, 2005 for $19,056 .39
. The balance
of the deductible in the amount of $81,033 .61 is being deducted from this payment . In addition
to the deductible, there are costs from this claim that are not being paid . Listed in Attachment A
are the costs that are not being paid and the reasons these costs are not being paid
.
On April 17, 2006, the Agency received your complete application for payment for this claim .
As a result of the Agency's review of this application for payment, a voucher for $28,845 .42 will
be prepared for submission to the Comptroller's Office for payment as funds become available
based upon the date the Agency received your complete request for payment of this application
for payment. Subsequent applications for payment that have been/are submitted will be
processed based upon the date complete subsequent application for payment requests are
received by the Agency. This constitutes the Agency's final' action with regard to the above
application(s) for payment.
ROCKFORD-4302 North Main Street, Rockford, It 61103-(815) 987-7760 • DES PLAINFS-9511 W . Harrison St., Des Plaines, IL 60016-(847) 294-4000
ELGIN -595 South State, Elgin, IL 60123-(847) 608-3131 • PEORIA-5415 N
. University St., Peoria, IL 61614-(309) 693-5463
BUREAU of LAND - PEORIA-7620 N . University St.,
Peoria, IL 61614-(309) 693-5462 • CHAMPAIGN-2125 South First Street, Champaign, IL 61820-(217) 278-5800
SPRINGFIELD-4500 5 . Sixth Street Rd .,
Springfield,
IL 62706-(217) 786-6892
COLLINSVILLE-2009 Mail Street, Collinsville, IL 62234-(618) 346-5120
MARION - 2309 W . Main St.,
Suite 116, Marion, IL 62959 - (618) 993-7200
PRINTED ON RECYCLED PAPER
ILLINOIS ENVIRONMENTAL PROTECTION AGENCY
Page 2
An underground storage tankk owner or operator may appeal this final decision to the Illinois
Pollution Control Board (Board) pursuant to Section 57 .8(i) and Section 40 of the Act by filing a
petition for a hearing within 35 days after the date of issuance of the final decision . However,
the 35-day period may be extended for a period of time not to exceed 90 days by written notice
from the owner or operator and the Illinois EPA within the initial 35-day appeal period . If the
applicant wishes to receive a 90-day extension, a written request that includes a statement of the
date the final decision was received, along with a copy of this decision, must be sent to the
Illinois EPA as soon as possible .
For information regarding the filing of an appeal, please contact
:
Dorothy Gunn, Clerk
Illinois Pollution Control Board
State of Illinois Center
100 West Randolph, Suite 11-500
Chicago, Illinois 60601
312/814-3620
For information regarding the filing of an extension, please contact :
Illinois Environmental Protection Agency
Division of Legal Counsel
1021 North Grand Avenue East
Springfield, Illinois 62794-9276
217/782-5544
If you have any questions or require further assistance, please contact Susan Brock of my
staff at 217/782-6762.
Dou
E. Oakley, Manager
Leaking UST Claims Unit
Planning & Reporting Section
Bureau of Land
DEO:SB
:mls\062359.doc
Attachment
cc:
Kowalenko & Bilotti, Inc .
Re:
LPC #0310515269 -- Cook County
Cicero/Former Manufacturing Site
1910-2100 South 54th Avenue
Leaking UST Incident No . 20040465
Leaking UST FISCAL FILE
Citations in this attachment are from the Environmental Protection Act (Act) in effect prior to
June 24; 2002, and 35 Illinois Administrative Code (35 Ill . Adm. Code) .
Item # Description of Deductions
1 .
$60,695 .35, deduction for costs for corrective action or indemnification that were
incurred prior to the owner or operator providing notification of the release to the
Illinois Emergency Management Agency (IEMA, formerly IESDA) (Section 57
.8(k) of
the Act and 35 Ill. Adm. Code 732 .606(n)).
The following costs were incurred prior to the IEMA notification date of April 7,
2004
:
a. S .C .I
. invoice dated January 28, 2004 for demolition work ($10,000 .00).
b. R.W. Collins invoice #114255, dated December 31, 2003 for sludge disposal
($3,850.00).
c. Chicagoland Truckin, Inc . invoice #1108, dated March 2, 2004 for backfill
($12,000.00).
d. Van Hoesen Industries invoice #33779, dated July 31, 2003 for liquid disposal
($15,588.75).
e. Van Hoesen Industries invoice #35394, dated April 7, 2004 for liquid disposal
($16,948.00) (shipping date, April 6, 2004) .
f. R.W. Collins invoice #10270, dated April 20, 2000 for initial soil remediation
($1,875.60).
Attachment A
Accounting Deductions
g.
STAT Analysis invoice #700417, dated March 17, 2000 ($273.00)
.
h. STAT Analysis invoice #700516, dated April 19, 2000 ($160
.00).
Page 2
2.
$23,462 .50, deduction for costs for the removal, disposal, or abandonment of an
underground storage tank that was removed or abandoned, or permitted for removal or
abandonment, by the Office of the State Fire Marshal before the owner or operator
provided notice to the Illinois Emergency Management Agency of a release of
petroleum (Section 57 .8(j) of the Act and 35 I11
. Adm
. Code 732.606(k)).
Deduction for costs for corrective action or indemnification that were incurred prior to
the owner or operator providing notification of the release to the Illinois Emergency
Management Agency (IEMA, formerly IESDA) (Section 57 .8(k) of the Act and 35111 .
Adm. Code 732 .606(n)) .
The following costs for UST removal were incurred prior to the IEMA notification
date of April 7, 2004 . Planned tank removal costs are ineligible
.
a. R.W. Collins invoice #113818, dated August 25, 2003 ($1,650 .50).
b.
R.W
. Collins invoice #114473, dated April 22, 2004 ($19,349 .50).
c.
Personnel, Page G-1
: UST Removal Oversight ($1,360 .00) ; Project
Coordination/Communication ($1,102 .50).
3 .
$200.00, deduction for costs which are unreasonable as submitted . (Section 57 .7(c)(4)
of the Act and 35111 . Adm. Code 732 .606(hh))
STAT Analysis invoice #6316, dated May 6, 2004 : The amount requested on Page F-
1 of the billing forms did not reflect the 8% discount given by STAT Analysis
($200 .00).
4.
$75 .96, adjustment in the handling charges due to the deduction(s) of ineligible costs
(Section 57 .8(f) of the Act and 35 Ill . Adm. Code 732 .607).
STAT Analysis invoices ($75.96).
5.
$1,053 .00, deduction for costs associated with demurrage charges . (Section 57.7(c)(4)
of the Act and 35 111 . Adm. Code 732 .606(nn))
Deduction for costs for an activity in excess of that necessary to meet the minimum
requirements of Title XVI of the Act (Section 57 .5(a) of the Act ; 35 I11 . Adm. Code
732.505(c) and 732 .606(0)). Costs for corrective action activities and associated
materials or services exceeding the minimum requirements necessary to comply with
the Act are not eligible for payment from the Fund (35 Ill . Adm. Code 732 .606(o)). In
addition, these costs are not corrective action costs . "Corrective action" means an
activity associated with compliance with the provisions of Sections 57 .6 and 57.7
of
the Act (Section 57 .2 of the Act and 35 Ill . Adm. Code 732 .103). One of the eligibility
Page 3
requirements for accessing the Fund is that costs are associated with "corrective
action" (Section 57 .9(a)(7) of the Act) .
a.
VanHoesen Industries invoice #35408, dated April 8, 2004 ($156 .00).
b.
VanHoesen Industries invoice #35464, dated April 15, 2004 ($546 .00) .
c.
VanHoesen Industries invoice #35580, dated April 30, 2004 ($351 .00) .
$85,486.81 Total Accounting Deductions
SB/mls/0623510 .doc,
General Office
217-785-0969
FAX
217-782-1062
Divisions
ARSON INVESTIGATION
217 .782-9116
BOILER and PRESSURE
VESSEL SAFETY
217-782-2696
FIRE PREVENTION
217-785-4714
MANAGEMENT SERVICES
217-782-9889
IN FIRS
217-785-5826
HUMAN RESOURCES
217-785-1026
PERSONNEL STANDARDS
and EDUCATION
217-7824542
PETROLEUM and
CHEMICAL SAFETY
217-785-5878
PUBLIC INFORMATION
217-785-1021
WEB SITE
w n'slale
.il .uslostm
State
Office
Fire
of the
-Marshal
Illinois
CERTIFIED MAIL - RECEIPT
REQUESTED #7003 3110 0004 1282 1524
December 28, 2004
I
American National Bank & Trust Co
.
Land Trust 124234-06
2035 W
. Giddings Street
Chicago, IL 60625-1416
In Re :
Facility No
. 2-039476
IEMA Incident No . 04-0465
Former Manufacturing Site
2100 S . 5415
Avenue
Cicero, Cook Co
., IL
Dear Applicant
:
The Reimbursement Eligibility and Deductible Application received on December 10, 2004 for the
above referenced occurrence has been reviewed
. The following determinations have been made based
upon this review.
It has been determined that you are eligible to seek payment of costs in excess of $100,000
. The costs
must be in response to the occurrence referenced above and associated with the following tanks
:
Eligible Tankq
Tank 1
30,000 gallon Heating Oil
Tank 2 20,000 gallon Heating Oil
You must contact the Illinois Environmental Protection Agency to receive a packet of Agency billing
forms for submitting your request for payment
.
An owner or operator is eligible to access the Underground Storage Tank Fund if the eligibility
requirements are satisfied
:
Neither the owner nor the operator is the United States Government,
2 .
The tank does not contain fuel which is exempt from the Motor Fuel Tax Law,
3 .
The costs were incurred as a result of a confirmed release of any of the following substances
:
"Fuel", as defined in Section 1
.19 of the Motor Fuel Tax Law
Aviation fuel
Heating oil
1035 Stevenson Drive •
Springfield, Illinois 62703-4259
Printed on Recycled Paper
Kerosene
Used oil, which has been refined from crude oil used in a motor vehicle, as defined in Section
1 .3 of the Motor Fuel Tax Law .
4.
The owner or operator registered the tank and paid all fees in accordance with the statutory and
regulatory requirements of the Gasoline Storage Act .
5.
The owner or operator notified the Illinois Emergency Management Agency of a confirmed release, the
costs were incurred after the notification and the costs were a result of a release of a substance listed in
this Section
. Costs of corrective action or indemnification incurred before providing that notification
shall not be eligible for payment
.
6.
The costs have not already been paid to the owner or operator under a private insurance policy, other
written agreement, or court order .
7.
The costs were associated with "corrective action" .
This constitutes the final decision as it relates to your eligibility and deductibility . We reserve the right to
change the deductible determination should additional information that would change the determination become
available . An underground storage tank owner or operator may appeal the decision to the Illinois Pollution
Control Board (Board), pursuant to Section 57 .9 (c) (2)
. An owner or operator who seeks to appeal the decision
shall file a petition for a hearing before the Board within 35 days of the date of mailing of the final decision, (35
Illinois Administrative Code 105 .102(a) (2)).
For information regarding the filing of an appeal, please contact :
Dorothy Gunn, Clerk
Illinois Pollution Control Board
State of Illinois Center
100 West Randolph, Suite 11-500
Chicago, Illinois 60601
(312) 814-3620
If you have any questions, please contact our Office at (217) 785-1020 or (217) 785-5878
.
eanne Lock
Administrative Assistant
Division of Petroleum and Chemical Safety
cc:
IEPA
Facility File
Leaking Underground Storage Tank Fund
Eligibility and Deductible Application
All underground storage tank owners or operators planning to seek reimbursement of corrective action costs
from the Leaking Underground Storage Tank (LUST) Fund must submit this application
. Instructions and
definitions to aid
in completing the application are attached .
The application must be completed in its entirety . Answers of unknown are not acceptable and will be
grounds for returning your application . All signatures and seals must he originals signed in ink . Incomplete
applications will be returned to the . applicant . Any revisions to the original application must be dated and
initialed by the person entering the new information . This must be the same person who signs the application .
If a facility is not in compliance with registration requirements, the application will be returned
.
Do not submit IEPA reports or bills with the application
A duplicate copy of the application is not
required
. Following the review of the application, the applicant will receive a certified letter of eligibility
stating the deductible amount.
1 . Name of ApplicantTank
Owner
:
:
Awt
_
.e,rieantL
OSFM Facility
Tank Operator
NG-hywwl
ID #:
_
2
13,,,k
-
(
03
check
5
all
`f¢ 7
that
/
,t
riujt
currently
apply)1/tt
23N-Oh
2. Current
Mailing
Contact
City: Address
PersonOwner
:
:
of
Applicant
Rh,trir/F
t, J y
:
(GIs
2,0
Smvt,i3Nk1{auet r
S
a
o
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o'k
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.
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671
RAhk
i
o
f
State
j{
:
9
(
L
T -G
{ruff
0
/7-N1-34-0G
Zip:
&04 2' c
Tank k Property
: Lessee
: (check. all that currently apply)
Mailing Address : 2_0
S W (rn
JdilT
Phone
City :
:(
(,(., toeLr •State : { L Zip : _4Q 6
7-
c
a)
7
Date
7
Facility
3)
U17-031L,
Property Purchased
: l D -T- IY
Leased:
b) Were tanks in the ground on date of purchase/lease? Yes x
No __
d)
c)
Have
If no,
you
were
ever
they
operated
installed
these
after,
tanksyour ;
purchase/lease?pumped
product
in
o
during the ordinary course of
operation?
The OSFD4 is requesting disclosure of information
Yes
to process
C
your
Eligibility
No
and Deductible Application in order to accomplish the statutory purpose as
slated in 415 ILLS, Act 5, Environmental Protection Act . This is REQUIRED because failure to provide the
requested information will result in this form
not being processed, and there will be no eligibility or deductible dctcrmbiation for purposes of the LUST Fund
. This form has been approved by the
Forms Management Center .
1
3. Previous owner/operator:
PmhA,1
i'1ti
c4i wt . S1t-C.ia/15-/-/
T4,4
Tank:
X
Property : )
_
Lessee : (check
all that currently apply)
PhoneCityCurrent
: :(mailing
address : State
: Zip:
4.
Facility
Facility
AddressName
: )
: /goo-
FD rW44-
Z/
At1
D C
h4f
.
a
in
5rt11-
City:
[hit.
56
.
.
Name
Occurrence
and official
for which
title
you
(SIC'of
intend
the
CV-0person
to
seek
who notified
reimbursementIEDLA
:
of
Incident
the occurrenceCounty#
:
2-00
:
Cork
If
(v
OVwr
(0
23 raE,4t t-S t f4
7. Other
Froincident
j -o(
numbers
M4M
reported
vW at
the site : (4separate
Date Reportedapplication
:
AP
must
r.
be fledfor
7)
2Deach o
occurrence
V
. Please
indicate if any of the additional incident numbers are erroneously reported incidents, or a second reporting of the
same occurrence for which you intend to seek reimbursement)
Other Incident Numbers
Date Reported
1)
2)3)
2ODttOn~712-nV'f"
Frevvte-ow5 ly
R-OrkJ
A-prfl-c
.
.
Ih,
q
/ 19
2ve9
9
8 . Total number of USTs at the site : L (include
USTspresently at the site and USTs that have been
removed or abandoned in place)
9 . Total number of USTs.at
the site that have had a release: 2- (An
UST release includes a leak
from an underground tank, a release from underground piping associated with the tank, plus
overfills
of the UST
duringfilling.)
10
. Type of release: (check all that apply)
Answers of unknown will not be accepted
.
UST leak Overfill
of an UST during filling
X
Underground piping leak Other
(detailed description required)
a) How was the release discovered? (check all that apply)
Inventory Loss Subsurface
Investigation
Product in Observation Well Significant
Event (I. e.,
overfill, vandalism, etc)
Subsurface
Work/Repair
X Other (detailed
description required)
O S T R+-"ra
i
b) Date release discovered :.Apr . ra t
S-D D 2
11. Is the UST owner or operator the U
.S. government?
Yes No
X
12
. Is the UST owner or operator a rail carrier registered pursuant to Section 18c-7201 of the Illinois Vehicle Code?
Yes No y
13
. Is the UST located at an airport with over 300,000 operations per year, for years prior to 1991
; and over 170,000
operations per year beginning in 1991, located in a city of more than 1,000,000 inhabitants?
Yes
No X
14
. Date corrective action work began or scheduled to begin
:
OO
V
15
. Date corrective action work completed
:
Dzt,t" 1w
2n o
The following certification must be completed by the UST owner/operator
:
, Ana, Sa,-1r))'k
the Owner,
Operator or designated agent of,
4'r
j
/JF
4
3
leaking underground storage tank site, do hereby
certify under penalty of law, that this application and the supporting documentation attached hereto were prepared under
my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered
and evaluated the information submitted therein
. I affirm that the information is, to the best of my knowledge and belief,
true, accurate and complete
. Such affirmation is made under penalty of perjury as defined in Section 32-2 of the
Criminal Code, 720 ILCS 5/32-2
. 1 am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowingly committing violations
. The "Eligibility and Deductible
Determination" decided pursuant to this
current is subject to the costs defined in Title 35
: Environmental Protection
Illinois Administrativ C e (IA ) 7 1,
742 and Public Act 92-0554
.
Signature
(owner, o
DateTitle
:
:
IV . 27-
,20 of
Subscribed and sworn to before me this~~~~
day of
VIUU~WIp~~I 20
Q`f
(application must be notarized when the cert ficate is signed)
1
,1_
't11
01
3
OFFICIAL
SEAL
KECIA NEELY
NOTARY PUBLIC
•S
TATE 061LuNOIS
MY COMMISSION EXPIRES
:10e3jT
,
Seal
Note
: Original signatures in ink and seals are required for the certification and notarization
. Attach the UST information
sheet behind this page
. This form may be reproduced on a
copier but cannot be altered in any
w ay. D O
NOT reproduce on
a computer
; this will be grounds for rejection
.
UST Information Sheet
The information below must be provided for each UST at the site . (USTs presently at the site and USTs that have been removed or abandoned)
All spaces must be completed for each tank- Answers of unknown will not be accepted
Please photocopy this page it' more space is needed
OSFNI Facility Ill # : 2 -0
31 V 71o
j
Circle one under each column .
Tank
Product
Size
Date
Date
Date Out of
Date
IEMA
Date IEMA
Registration
Has UST
Is UST
1D#
Code
(Gallons)
Installed
Registered - Service
Removed
Number
Notified
Fees Paid
Had a
Legally
Release
Abandoned
In-Place?
Il 3o1
n-v
l9 VP-
/7-,Tim-03 0b-Avr_._cyr
2ooyoysf'
o7-Apr.-oY
® N
D N
7- M I-PI" -V
/q y0 17-Ju .-e,7
/9X'~
O6~r-oy.2ocwoVL5
D7-AprD 1 t
6)
N
Q N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Product Codes - (refer to .instruclionsfor definitions)
: G-Gas, D
- Diesel,
A - Aviation fuels, K- Kerosene, M- New Motor Oil or U - Used oil ; H - Heating oil ; HAZ- Hazardous
Substance (description required)
;
N - Any product not included under another code. (description required)
4
Y N YN
YN YN
YN YN
YN YN
YN Y N
Y N' Y N
Y N YN
YN YN
r
I
TOvq
KOUJALENKQ-& BROTH, INC
eN
I79 NoM Pewla
O,
S 07
Suit
. S Nwt
I,ogo .llllrolz 60607 USA
V . CERMAK RD.
DATE: 05/2004 SCALE : 1" = 60'
FZ~1 i`
DRAWN BY : WK CHECKED BY : TB
American
SITEPLANNational
,TrutNo.12423406
K&B PROJECT No . 03-EPRA-013 .
210.0 S. 54th St, .
CHICAGO, ILLINOIS
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Label/Receipt Number
: 7004 2510 0001 8593 1152
Status : Delivered
Your item was delivered at 12 :58 pin on May 17, 2006 in CHICAGO, IL
60607 .
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