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FIED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of VL PIPING CONSTRUCTION(check a0 thtt vpiv) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE .PRESSURE [12.SUCTION ❑3.GRAVITY 458. ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ El 1.SINGLE WALL ❑3.LIKED TRENCH ❑99.OTHER 4611 ❑1.SINGLE WALL [195.UNKNOWN 461. MANUFACTURER ,DOUBLE WALL ❑95.UNKNOWN [12.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463. ❑1.BARE STEEL ❑6.PEP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL [12.STAINLESS STEEL [17.GALVANIZED STEEL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WPP CONTENTS [195.UNKNOWN [j3.PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) [199.OTHER [14.FIBERGLASS L-7/8.FLEXIBLE(HDPE) ❑99.OTHER [14.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/CO.ATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL WCOATING [195.UNKNOWN 465. -: VILPIPINGLEAK DETECTION Check aU that Ij(A:dacri ofthe nnnitorin o8rua shall be submitted io Uw kcal ea -- UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 4 7. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check ail that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TESTµTIT{ 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. [12. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) 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 [39. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY PLOW(Check all that apply): [18. DAILY VISUAL MONITORING E19. 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 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL AALAYMS AND(Check one) ALARMS AND(Check one) OPS. 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 []c. NO AUTO PUMP SHUT OFF [3 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)W< FLOW SHUT E311 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION [112. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM El 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 (3.0 GPH TEST) WITHOUT FLOW [115.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPM ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) []J7. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK DISPENSER CONTAINMENT 468, Q 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS E15. TRENCH/LINER MONITORING 1 rw CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS _. IX:OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATUREOFOWNER/OPERATOR _ /l DATE: 7 Zyv 470 NAME OF OWNER/OPERATOR(print): aQ n /[./p�G TITLE OF OWNER/OPERATOR: 00/#/£'f- 472' .7�A�4172 �y/Y Permit Number(Agency use only) 473. Permit Approved By(Agency we only) 474. 1 Per®/Eapitation Date(Agency use only) 475. UPCF bwfwrc-b(1/99)-3/4 http://www.unidm&org Rev.02/16M