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V UNIFIED PROGRAM CONSOLIDATED FORM TANKS IIIR UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION (Check a# that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 99. OTHER ❑ 1. SINGLE WALL 1195. CONSTRUCTION/ UNKNOWN MANUFACTURER X2. DOUBLE WALL 1195. UNKNOWN ❑ 2. DOUBLE WALL 1199. OTHER MANUFACTURER MANUFACTURER ❑ 1. BARE STEEL 8. FRP COMPATIBLE WI 100% METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COMPATIBLE W/ 100% METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 1:195. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ S. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL All COATING ❑ 9. CATHODIC PROTECTION ❑ 5 STEEL W/ COATING ❑ 95. UNKNOWN VII. PIPING LEAK DETECTION (Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING IPING SINGLE WALL PIPING PIPING (Check all that apply): APTELECTRONIC PRESSURIZED PIPING (Check all that apply): LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL SYSTEM FAILURE, AND SYSTEM DISCONNECTION -;AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 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 + TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST (0.1 GPH) ❑ 8. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW (Check all that apply): ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check all that apply). PRESSURIZED PIPING (Check all that apply): 10. CCONckNonOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (check one) 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 GPM 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 ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF + AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF +AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 18. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VUL DISPENSER CONTAINMENT DISPENSER CONTAINMENT X 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DAT I S A ED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/ MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER +AUDIBLE AND VISUAL ALARMS ❑ 8. NONE IX. OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNERIOPERATOR DATE NAME OF OWNER/OPERATOR (print) TITLE OF OWNER/OPERATOR Permit Number (For local use only) Pertnit Approved (For local use only) [_Permit Expiration Date (For local use only) CUPAFORM (4/99) Formerly SWRC8 Form B