BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

UPCF (12/99 revised) 0 41 UNIFIED PROGRAM CONSOLIDATED FORM (I(�f'(/ 70/103 TANK: �� PR #: FAC #: UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI. PIPING CONSTRUCTION (chtth all maz apply) PaM 3 of3 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ L PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 ❑ I. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 CONBTRUCDON ❑1. SINGLE WALL 03. LINED TRENCH ❑ 99. OTHER 460 ❑ I. SINGLE WALL ❑ 95.UNKNOWN 462 ❑2.DOUBLEWAL.L ❑95.UNKNOWN El 2. DOUBLE WALL 99. OTHER MANUFACTURER 061 MANUFACTURER 463 ❑ I. BARE STEEL ❑ 6. FRP COMPATIBLE a I00Y. METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w 140X METHM IOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 91 UNKNOWN ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ ".OTHER ❑ 4. FIBERGLASS ❑ S. FLEXIBLE (HOPE) ❑ 95. OTHER ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 I ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 465 VEL PIPING LEAK DETECTION (Clark A flu, apply) (Adaeiptico of he mmitamgpro®amaldlbcaubtmtdro tat lord agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AU'DO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+ UDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TE 3T (0.1 GPH) ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYS INTEGRITY TEST (0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPIN ❑ 7. SELF MONITORING ❑ ]. SELF MONITORING GRAVITY FLOW ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH GRAVITY FLOW (Check all that apply): ❑ 8.DAILYVISUALMONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Cheek all that apply): PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VIS AL ALARMS AND (Chookax) ALARMS AND (ChnA.) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILUN AND SYSTEM ❑ It. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL S EMERGENCY GENERATORS ONLY (Cha all Wt apply) EMERGENCY GENERATORS ONLY(ChwA all Naz apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF • ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ I5. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VILE. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATEINSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+ AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER /MONI ORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6. NONE DISPENSER +AUDIBLE AND VISUAL ALARMS 469 IX. OWNER/OPERATOR SIGNATURE I cntfythat We iafmretion prey al hartin h true and accurate to the beat ofay bwwld8 SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR (print) TITLE OF OWNER/OPERATOR 47t az Pcmut Namber(Fw local use ady) 473 RcratAppmal(Fmladaaemdy) 474 Pemut Expiradun[)ate(For laal use arty) 475 UPCF (12/99 revised) 0 41