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FIED PROGRAM CONSOLIDATED FORT <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> Pa a oC <br /> *. .. VI.PIPING CONSTRUCTION(Chukau(nA ly) - <br /> UNDERGROUND PIPING <br /> ABOVEGROUND PIPING <br /> SYSTEM TYPE 1.PRESSURE [12.SUCTION [13.GRAVITY 458. [11.PRESSURE D 2.SUCTION D 3.GRAVITY 459. <br /> CONSTRUCTION/ /1.gINGLE WALL [13.LINED TRENCH D 99.OTHER 4W. D L SINGLE WALL D 95.UNKNOWN 462. <br /> MANUFACTURER I 2 DOUBLE WALL D 95.UNKNOWN [12.DOUBLE WALL D 99.OTHER <br /> MANUFACTURER 461. MANUFACTURER 463. <br /> D 1.BARE STEEL D 6.FRP COMPATIBLE W/100%METHANOL [11.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL <br /> [12.STAINLESS STEEL D 7.GALVANIZED STEEL D 2.STAINLESS STEEL D 7.GALVANIZED STEEL <br /> D 3.PLASTIC COMPATIBLE T H CONTENTS D 95.UNKNOWN D 3.PLASTIC COMPATIBLE W/CONTENTS D S.FLEXIBLE(TOPE) [199.OTHER <br /> [14.FIBERGLASS 8.FLEXIBLE(HDPE) D 99.OTHER [14.FIBERGLASS [:19.CATHODIC PROTECTION <br /> D 5.STEEL W/C0.4TING D 9.CATHODIC PROTECTION 464. D 5.STEEL W/COATING [195.UNKNOWN 465. <br /> VII.PIPING:LEAKDETECTION Chec1ca0.that I)(A:descri am ortlle tipnho' sM1a114 submhudtothe kxal <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> D 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WI AUTO PUMP [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM AUTO PUMP <br /> SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. <br /> D 2. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST <br /> [13. ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> D 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): [36. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> D 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW D7. SELFMONITORING <br /> [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> [19. 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. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> AL S AND(Check one) ALARMS AND(Check one) <br /> a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS D a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> D b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM D b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Dc. NO AUTO PUMP SHUT OFF Dc. NO AUTO PUMP SHUT OFF <br /> ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT D 11 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) D 12.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS D 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> []14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> [315. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW D 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> 016. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [117. DAILY VISUAL CHECK D 17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 468. D1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. <br /> DATE INST ED 2 -D 22.. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING?� F CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR D6. NONE <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> • ' IX.OWNERIOPERATOR SIGNATURE <br /> I certify that the information provided herein js true and accurate to the best of my knowledge. <br /> SIGNATURE OF OWNER/OPERATOR DATE: Z� /„p 470_ <br /> NAME OF OWNER/OPERATOR(print); - TITLE OF OWNER/OPERATOR: Io / 4M. <br /> Pcook Nomber(Agency use only) 473. Permit Approved By(Awncy use only) 474. Petmi[Eapiralion Date(Agevcy use only) 475. <br /> UPCF hwfwrc-h(1/99)-3/4 http://www.unidoes.org Rev.02/16/00 <br />