Information

JB Pritzker, Governor

James A. Rivera, State Fire Marshal

Division of Petroleum & Chemical Safety

State of Illinois
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Division of Petroleum & Chemical Safety

Facility Details

Facility Number:	2001090
Status:	Closed
Facility Name:	Adjustable Forms, Inc.
Address:	1 East Progress Road Lombard, IL 60148
County:	Du Page
Property Parcel:
Facility Type:	Commercial / Retail
Owner Type:	Private
Green Tag Decal:	M005274
Green Tag Issue Date:	5/19/2011
Green Tag Expiration Date:	12/31/2013

Owner Details

Owner Name:	Adjustable Forms, Inc.
Owner Address:	1 East Progress Road Lombard, IL 60148
Owner Status:	Current Owner
Purchase Date:	6/7/1982
Type of Financial Responsibility:	Commercial Insurance
Financial Responsibility Reporting Due Date:	6/27/2012

Motor Fuel Dispensing Permits

No MFD Permits Found

Owner Summary

Click for Facility/Tank Ownership history

Owner Number	Owner Name	Owner Status	Purchase Date
U0000218	Adjustable Forms, Inc.	Current Owner	6/7/1982

Permits (Unexpired)

Click for permit history

No Active Permits Found

Deficiencies (Current)

No Deficiencies Found

IEMA Numbers Associated with the Facility

IEMA Number	Inspection Date	Inspection Type	Permit Number
11-1153	11/17/2011	Removal Log	01079-2011REM

LUST Fund Eligibility and Deductibility Determinations

IEMA Number	Status	OSFM Received Date	OSFM Response Date	Deductible	Letter
11-1153	Eligible	12/14/2011	2/16/2012	$5,000

Pay Tank Fees Online

Tank Information

Tank Number 1

Capacity:	2000		Petroleum Use:
Product:	Diesel Fuel		CERCLA Substance:
Status:	Removed		CAS Code:
Regulated Status:	Federal		Removed Date:	11/17/2011
OSFM First Notify Date:	1/29/1986		Abandoned Material:
Current Age:	29		Abandoned Date:
Install Date:	8/1/1982		Red Tag Issue Date:
Last Used Date:			Fee Due:	$0.00
Product Date:	10/1/1982

Equipment

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Corrosion Prot - Piping	Fiberglass Non-Corrosive	N/A	N/A
Corrosion Prot - Tank	Fiberglass Non-Corrosive	N/A	N/A
Leak Detect - Piping	European with No Test Req Suction	N/A	N/A
Leak Detect - Tank	Automatic Tank Gauging Veeder Root TLS 350
Overfill Prev Device	Overfill Drop Tube Valve
Piping	Fiberglass Single Wall Piping	N/A	N/A
Spill Contain Device	Single Wall Spill Bucket
Tank	Fiberglass Single Wall	N/A	N/A

Additional Tests

Equipment Type	Equipment	Test Type	Test Result	Test Date

Tank Number 2

Capacity:	2000		Petroleum Use:
Product:	Gasoline		CERCLA Substance:
Status:	Removed		CAS Code:
Regulated Status:	Federal		Removed Date:	11/17/2011
OSFM First Notify Date:	1/29/1986		Abandoned Material:
Current Age:	29		Abandoned Date:
Install Date:	8/1/1982		Red Tag Issue Date:
Last Used Date:			Fee Due:	$0.00
Product Date:	10/1/1982

Equipment

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Corrosion Prot - Piping	Fiberglass Non-Corrosive	N/A	N/A
Corrosion Prot - Tank	Fiberglass Non-Corrosive	N/A	N/A
Leak Detect - Piping	European with No Test Req Suction	N/A	N/A
Leak Detect - Tank	Automatic Tank Gauging Veeder Root TLS 350
Overfill Prev Device	Overfill Drop Tube Valve
Piping	Fiberglass Single Wall Piping	N/A	N/A
Spill Contain Device	Single Wall Spill Bucket
Tank	Fiberglass Single Wall	N/A	N/A

Additional Tests

Equipment Type	Equipment	Test Type	Test Result	Test Date

Dispenser Information

MFD Motorfuel Dispensing Forms

No Forms Found