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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Page of ;pIPINGCO $TRUCTION(check an uwapply)!' UNDERGROUND PIPINGABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE [12.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION [13.GRAVITY 459. CONSTRUCTION/ f-1 1.SINGLE WALL El 3.LINED TRENCH [199.OTHER W. [11.SINGLE WALL ❑95.UNKNOWN 462 MANUFACTURER 2/DOUBLE WALL [195.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463. ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL 0 1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL [12.STAINLESS STEEL ❑7.GALVANIZED STEEL [12.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE CONTENTS [195.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HOPE) [199.OTHER [14.FIBERGLASS 8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 [15.SITEL W/COATING ❑95.UNKNOWN 465. _VH.PIPING LEAK DETECTION(cneck all Inst ly)(A htev ortns nnnitai - mem snail tie sabmTtedioil«:)6ci5 I NDERGROIIND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466_ SINGLE WALL PIPING 461. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W AUTO PUMP [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST AUTOPUMP 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. [12. MONTHLY 02 GPH TEST ❑2. MONTHLY 0.2 GPH TEST [13. 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 [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 136. TRMNNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. DAILY VISUAL MONITORING [J9. 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. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 30. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALytMS AND(Check one) ALARMS AND(Check one) a. 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 Oc. NO AUTO PUMP SHUT OFF Oc. NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)MM FLOW SHUT �11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. 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&I tat apply) [314. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHIT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS (115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITTIONT FLOW ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [116. ANNUAL INTEGRITY TEST(0.1 GPI [316.ANNUAL INTEGRITY TEST(0.1 GPH) []17. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE []4. DAILY VISUAL CHECK 469. DATE INST LED 2 -[12.2. UT CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15. TRENCH/LINER MONITORING 'j Llys. CONTINUOUS DISPENSER PAN SENSOR A= AUTO SHOFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS [3 6. NONE I certify that the information provided herein's true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE:R/OZ� /}p 490. NAME OF OWNEPERATOR(prmt): -- TITLE OF OWNER/OPERATOR::: a 472. Permit Number(Agency use only) 473 1 Per®[Approved By(Agency use only) 474 1 Permit Expiration Date(Agency ase only) 415. UPCF hwfwn-b(1/99)-3/4 http://www.unidocs.org Rev.02/16/00