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` �IFIED PROGRAM CONSOLIDATED FORiq TANK: TA0504846 <br />PR#: PRO231482 <br />FAC #: FA0000720 <br />DUNDERGROUND STORAGE TANKS - TANK PAGE <br />VI. PIPING CONSTRUCTION (Chak ah that appy) <br />aae ] o <br />] <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />SYSTEM TYPE ❑ 1. PRESSURE 2. SUCTION ❑ 3. GRAVITY 458 <br />❑ 1. PRESSURE ❑ 2. SUCTION [13. GRAVITY 459 <br />CONSTRUCOON ❑ 1. SINGLE WALL 03. LINED TRENCH ❑ 99. OTHER 40 <br />❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 <br />2.DOUBLEWALL ❑95.UNKNOWN <br />❑2. DOUBLE WALL ❑99.OTHER / <br />MANUFACTURER a61 <br />MANUFACTURER 463 <br />❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/ IM METHA110L <br />❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE w/ 100%METHANOL <br />❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL <br />❑ 2. STAINLESS STEEL [17. GALVANIZED STEEL <br />❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN <br />❑ PLASTIC COMPATIBLEW/CONTENTS [195. UNKNOWN <br />❑ 4. FIBERGLASS [18. FLEXIBLE (HDPE) ❑ 99.OTHER <br />❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER <br />la 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 <br />❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 465 <br />VII. PIPING LEAK DETECTION (Chsk an mat ap)y) (A dn*dM erthaCnatOr a pae®aa Shan be SU6aite i w me 1a4 aacaay) <br />UNDERGROUND PIPING ABOVEGROUND PIPING <br />SINGLE WALL PIPING 466 <br />SINGLE WALL PIPING 467 <br />PRESSURIZED PIPING (Check all that apply): <br />PRESSURIZED PIPING (Check all that apply): <br />❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF <br />❑ L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF <br />FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+AUDIBLE AND <br />FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+AUDIBLE AND <br />VISUAL ALARMS. <br />VISUAL ALARMS. <br />❑ 2. MONTHLY 0.2 GPH TEST <br />❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) <br />❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) <br />❑ 4. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS <br />CONVENTIONAL SUCTION SYSTEMS (Check all that apply) <br />❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING <br />❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />INTEGRITY TEST (0.1 GPH) <br />❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): <br />SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): <br />❑ 7. SELF MONITORING <br />❑ 7. SELF MONITORING <br />GRAVITY FLOW <br />❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH <br />GRAVITY FLOW (Check all that apply): <br />❑ 8. DAILY VISUAL MONITORING <br />❑ 9.13IENNIAL INTEGRITY TEST (0.1) GPH <br />SECONDARILY CONTAINED PIPING <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check a6 that apply): <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />ALARMS AND (Chat oac) <br />ALARMS AND (Chakene) <br />❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />DISCONNECTION <br />❑ c. NO AUTO PUMP SHUT OFF <br />❑ C. NO AUTO PUMP SHUT OFF <br />❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR <br />❑ 11 AUTOMATIC LEAK DETECTOR <br />RESTRICTION <br />❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />SUCTION/GRAVITY SYSTEM <br />13. CONTINUOUS SUMP SENSOR, AUDIBLE AND VISUAL ALARMS <br />❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />EMERGENCY GENERATORS ONLY (Check all that appy) <br />❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF • <br />❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br />AUDIBLE AND VISUAL ALARMS <br />AUDIBLE AND VISUAL ALARMS <br />15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEWITHOUT FLOW <br />❑ ST) <br />❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW <br />SHUT OFF OR RESTRICTION <br />SHUT OFF OR RESTRICTION <br />❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) <br />❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) <br />❑ 17. DAILY VISUAL CHECK <br />❑ 17. DAILY VISUAL CHECK <br />VII. DISPENSER CONTAINMENT <br />DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK <br />DATEINSTALLED 468Vi2CONTINUOUS DISPENSER PAN SENSOR+ AUDIBLE AND VISUAL ALARMS ❑5. TRENCH LMER/MONITORING <br />I M❑V. 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6. NONE <br />DISPENSER+ AUDIBLE AND VISUAL ALARMS 469 <br />IX. OWNERIOPERATOR SIGNATURE <br />I ani thinformauovprovidcdhwemhvucand aaivaew6sbcstefmy kawwkdge <br />SIG WNEt f 4tTO <br />DATE L/'��] D 470 <br />NAME OF OWNER/OPERATOR(print) <br />TITLE OWNER/OPE TOR <br />4)1 <br />f . > 4]z <br />Pmnii Nunber(Forlmalmeenly) 473 Penni, A6oa <br />ppaove(F., lf ma.*) 44774i1•J Paanit Expiation Date (For local use only) 475 <br />PT0000724 EE0003804 6/30/2003 <br />UPCF (12/99 revised) <br />