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r ti ' �IFIED PROGRAM CONSOLIDATED FOR4 TANK: TA0504844 PR#: PR0231482 F C #: FA0000720 UNDERGROUND STORAGE TANKS - TANK PAGE b VI. PIPING CONSTRUCTION (Chak A tmt appy) P., nor UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1. PRESSURE 2. SUCTION ❑ 3. GRAVITY 458 ❑ 1. PRESSURE ❑ 2. SUCTION [13. GRAVITY 459 CONSMUCWN 1. SINGLE WALL ❑3. LINED TRENCH ❑99.OTHER 460 ❑I. SINGLE WALL El 95. UNKNOWN 462 ..El . DOUBLE WALL 095.UNKNOWN El 2. DOUBLE WALL ❑99.OTHER MANUFACTURER 061 MANUFACTURER 463 ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/ 10% METHANOL ❑ L BARE STEEL ❑ 6. FRP COMPATIBLE w/ m0%METHANOL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN ❑ 4. FIBERGLASS [18. FLEXIBLE(HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS [18. FLEXIBLE(HOPE) [199. OTHER 1, 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ S. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 465 VD. PIPING LEAK DETECTION(Chmk all Nat apply) (A aacaiptlon arae mmnitminep,,amsmll bcsubmiad w Nclacal asasy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK SYSTEM FAILURE, AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑ 2. MONTHLY 01 GPH TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (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 ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM 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 GROUNDPIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONTIORING GRAVITY FLOW ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (GAL GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply): PRESSURIZED PIPING (Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLEANDVISUAL ALARMS AND (Chock om) ALARMS AND (Cbwk wc) ❑ 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 FAILURE AND SYSTEM ❑ b. 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/GRAVDFV SYSTEM SUCTION/GRAVITY SYSTEM 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(C'hakau Wat appy) EMERGENCY GENERATORS ONLY (C all tmt appy) ❑ 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 15. 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.l GPH) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VIO. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1, FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED4dl'2. CONTINUOUS DISPENSER PAN SENSOR+ AUDIBLE AND VISUAL ALARMS E] 5. TRENCH LINER/MONITORING JJ❑moo'' 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6. NONE DISPENSER + AUDIBLE AND VISUAL ALARMS 469 IX. OWNER/OPERATOR SIGNATURE I 'fy t0a mfomu'I=pmv haciu u nua x ale w aN bat army I*L SI, TU F O NE PE TOR -�. DATE 470 3 NAME. O W NER/OPERATOR (print) TITLE OF OWNER/OPERATOR RC 471 YV ryiV`472 PmniNmnba(Fmloluacanly) 473 PmhApmvd(FmlmaluuuNy) 474Pmnit Expiation Wtc(F., bwl usconly) 475 PT0000724 EE0003804 6/30/2003 UPCF (12/99 revised)