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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pa of Vt.PIPING CONSTRUCTION check a06as UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑I.PRESSURE ❑2.SUCTION 3.GRAVITY 458. ❑L PRESSURE ❑2.SUCTION 3.GRAVITY 459. CONSTRUCTION/ 1.SINGLE WALL ❑3.LINED TRENCH .OTHER 460. ❑L SINGLE WALL 9 .UNKNO 48x. MANUFACTURER ❑ DOUBLE WALL ❑95.UNKNOWN [12.DOUBLE WALL 99.OTHER MANUFACTURER461. MANUFACTURER 463, 1.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL 1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ON, .STAINLESS STEEL ❑7.GALVANIZED STEEL 2.STAINLESS STEEL ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑S.FLEXIBLE(HDPE) ❑99.OTHER [14.FIBERGLASS ❑S.FLEXIBLE(HDPE) [199.OTHER [14.FIBERGLASS ❑9.CATHODIC PROT TI [15.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION((Mecs all Out ) A . ion of the Mattoon poagcun shall be submmd to the local UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check a0 that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Clack all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) \ GRAVITY FLOW(Check all that apply): ❑9. BAILY IENNIA INT MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING y :A+ZS 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 VISUAL ALARMS AND(Check one) ALARMS AND(Check me) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO PUMP SHAT 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. NOAUTOPUMPSHUTOFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11. AUTOMATIC LEAK DETECTOR ❑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) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (1.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) [116, ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK [117.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [34. DAILY VISUAL CHECK 469. DATE INSTALLED E12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING 6 ❑3. NTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR NONE PENS AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1 fy t t the information provid etei accurate to the best of my knowledge. GNAT OF OWNER/OPDATE: 1f 4770. V 0 NAM f'yF7M ) I t TITLE OF OWNE OPERATOR: Pemut Number(Agency use only) Y /\(473. Permit Approved By(Agency ase only) 474. Permit Expiration Datc( y use only) 475. UPCF hwfwrc-b(1/99)-3/4 http://www.unidocs.org Rev.02/I6/00