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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 <br /> Pa e_of <br /> VI.PIPING CONSTRUCTION 0-k aR thu4 n ABOVEGROUND PIPINGUNDERGROUND PIPING <br /> 459 <br /> SYSTENI TYPE .PRESSURE El 2.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE [12.SUCTION ❑3.GRAVITY 462. <br /> CONSTRUCTION/ 1.SINGLE WALL [13.LINED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL ❑95.UNKNOWN <br /> MANUFACTURER '>-f,2-DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER <br /> 461. MANUFACTURER 463_ <br /> MANUFACTURER ri'P <br /> ❑1.BARE STEEL ❑6.FRP COMPATIBLE W1100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL <br /> ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑ <br /> 2.STAINLESS STEEL ❑7.GALVANIZED STEEL <br /> 99. <br /> [13.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑9.CATHOD C PROTECTION 8.FLEXIBLE(HDPE) ❑ OTHER <br /> ❑4.FIBERGLASS TX.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑ 465. <br /> ❑5.STEEL W/COATING C]9.CATHODIC PROTECTION <br /> eet. [35.STEEL W/COATING ❑95.UNKNOWN <br /> VII.PIPING LEAK DETECTION(ckaok.n mu. I)tAaaxa'knofthemnaonniEnolInnnsh•IIABOVEGtOWi DPIPING ) <br /> UNDERGROUND PIPING 467. <br /> SINGLE WALL PIPING 466. SINGLE WALL PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [31. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> SHUT-OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION +SHUT UA DOUBFF LE FOR <br /> L VISUAL ALARMS SYSTEM LURE,AND SYSTEM DISCONNECTION <br /> +AUDIBLE AND VISUAL ALARMS. <br /> ❑2. MONTHLY 0.2 GPH TEST <br /> ❑2. MONTHLY 0.2 GPH TEST <br /> ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL E TEST(0.1 GPH) <br /> - [3 4. DAILY VISSUALUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6.FE TRIENNIAL <br /> LITE INTEGRITY <br /> SUCVALVES IN BELOW GROUND PIPING): <br /> [3 7. SELF MONITORING <br /> GRAVITY FLOW [17. SELF MONITORING <br /> GRAVITY FLOW(Check all that apply): <br /> ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) (18. DAILY VISUAL MONITORING <br /> ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING - <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. COO TINUOUS TURBNCheckEJ SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALSALARMS AND(Check one) <br /> ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> jKb.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b. D T OPUMP SHUT <br /> OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> ION <br /> DISCONNECTION <br /> 11c. NO AUTO PUMPSHUT OFF ❑c. AUTO PUMP F <br /> DETECTOR <br /> 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT [3 I1.AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SU 13.CONTINUOUS <br /> SSYSTEM <br /> [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARFIS ❑ <br /> 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check ail that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑l4. OAOON-MUOUS AND VISUAL ALARMSUMP SENSOR S HOIfC AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS <br /> ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WiTHOU FLOW [115.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUTOFF OR RESTRICTION [116, ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [316. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17.DAILY VISUAL CHECK <br /> [317. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINDIENT <br /> DISPENSER CONTAINMENT 46a. �❑1./1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04. DAILY VISUAL CHECK 469. <br /> DATEINSTALLED >< CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING <br /> [13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE <br /> LMS <br /> IX.OWNER/OPERATOR SIGNATURE <br /> 1 certify that the information provided herein is true and actuate to the best of my knowledge. I 470 <br /> TU EDF E OPE TOR ✓ ^I �� <br /> DATE: g-/ -2- ( v2- <br /> (� 47x. <br /> TITLE OF OWNEROPERATOR: <br /> NAME OF OWNER/OPERATOR(print): ' <br /> 473. Permit APPmved BY(Agency we only <br /> 47J. Permit Expiration Dam(Agency use only) 475. <br /> Permit Number(Agency uu only) <br /> Rev.02/16/00 <br /> UPCF hwfwrc-b(1/99)-3/4 httpjlw .unidocs.org <br />