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UNIFIED PROGRAM CONSOLIDATED FORM p P TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 UNDERGROUND PIPING SYSTEM TYPE "5(I. PRESSURE ❑ 2. SUCTION CONSTRUCTION/ ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH MANUFACTURER "jd2 DOUBLE WALL ❑ 95. UNKNOWN MANUFACTURER j. M (-Ti4 fL ❑ I, BARE STEEL 6. FRP COMPATIBLE W/100% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL [l 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 95. UNKNOWN FIBERGLASS ❑ S. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464, ABOVEGROUND PIPING ❑ 3. GRAVITY 458. ❑ I. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459. ❑ 99. OTHER 460. ❑ I. SINGLE WALL [195. UNKNOWN 462. [12. DOUBLE WALL ❑ 99. OTHER I.Ul,6T 461. MANUFACTURER 463' ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100% METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 3. PLASTIC COMPATIBLE W/ CONTENTS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION [15, STEEL W/COATING ❑ 95. UNKNOWN 465 SINGLE WALL PIPING 466' PRESSURIZED PIPING (Check all that apply): 3.0 GPH TEST WITH AUTO PUMP ❑ 1. ELERNIC LINE LEAK DET SHUT-OFF FOR LEAK, SYSTEM F AIOLURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST (0.1 GPH) CONVENTIONAL SUCTION SYSTEMS ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING GRAVITY FLOW C]9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ;b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑ I I. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) []14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION [116. ANNUAL INTEGRITY TEST (0.1 GPH) 017. DAILY VISUAL CHECK SINGLE WALL PIPING 467. PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION + AUDIBLE AND VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5, DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM [36. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING GRAVITY FLOW (Check all that apply): [38, DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE- AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LEAK DETECTOR [112. ANNUAL INTEGRITY TEST (0. t GPH) SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITH UT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK VIII. DISPENSER CONTAINIYU&N I DISPENSER CONTAINMENT 468. ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED C12. CONTINUOUS DISPENSER PAN SENSOR+ AUDIBLE AND VISUAL ALARMS '%3. CONTINUOUS DISPENSER PAV SENSOR WITH AUTO SHUT OFF FOR DISPENSER + AUDIBLE AND VISUAL ALARMS IX. OWNER/OPERATOR SIGNATURE that the info/mjtij?n pjevided herein is true and accurate to the best of my NAME 0 N6R&E r4. Pem,it Number (Agency use only) 473. Permit Approved By (Agency use only) 474. UPCF hwfwrc-b (1/99) - 3/4 http://www.tsnidocs.org [14, DAILY VISUAL CHECK 469. ❑ 5. TRENCH/LINER MONITORING ❑ 6. NONE 470. L V4 N ion Date (Agency use only) 475. Rev. 02/16/00