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UNIFIED PROGRAM CONSOLIDATED FORM' TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pam of �,YIPING_C TRUCTION'i kA ihetap IA UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE PRESSURE [32:SUCTION El3.GRAVITY u8. [31.PRESSURE E32.SUCTION [33.GRAVITY 459. . CONSTRUCTION/ [1]1.S IE WALL ❑3.LINED TRENCH 0 99.OTHER Oso. ❑L SINGLE WAIL [195.UNKNOWN 462 MANUFACTURER DOUBLE WALL E3 95.UNKNOWN ❑2.DOUBLE WALL 13 DOUBLE MANUFACTURER mi. MANUFACTURER 4m. ❑1.BARE STEEL O 6.FEE COMPATIBLE W/100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL 117.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE Wj2H CONTENTS 1395.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑B.FLEXIBLE(HDPE) [3 OTHER ❑4.FIBERGLASS 8.FLEXIBLE(HDPE) [199.OTHER ❑4.FIBERGLASS [19.CATHODIC PROTECTION ❑5.STEEL W/ODATING ❑9.CATHODIC PROTECTION 454. ❑5.STFPL W/COATING ❑95 UNKNOWN 46s 3PIPDNG LEAK DETE (kd'i On ofwe rmdno' ' Stull be sub A"w ft local a. .. UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 455. SINGLE WALL PIPING ^� PRESSURIZED POING(Cbeck all haat app1Y): PRESSURIZED PIPING(Check all that apply): ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 CPH TEST HM AUTO PUMP [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MU AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAR,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 02 GPH TEST ❑2. MONTHLY 02 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) [34. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [35. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING E3 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(O.I GPI) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITYFIOW 07. SELF MONITORING C39. BIENNIAL INTEGRITY TEST(0.1 GRIT) GRAVITY FLOW(Check all that apply): ❑B. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPIs 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 ALA $deiS AND(Chale oro) ALARMS AND(Check one) W'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 Elc. NO AUTO PUMP SHUT OFF [3c. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) "EM FLOW SENT (]11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION [312. ANNUAL INTEGRITY TEST(0.1 GPI) ❑12.ANNuAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTIONK:RAVITY 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 ❑14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. 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 GPT) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [317. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK DISPENSER CONTAINMENT 468. [31. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [34. DAILY VISUAL CHECK 469. DATE INSTALLED ❑2.-- CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING p1i. Z 4 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 06. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS QRSIGNATURE I certify that the information provided herein is true and accutate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE: 2 470. f • - 7 ye . NAME OF OWNER/OPfiRATOR(ptm): TITLEOFOWNER/OPERATOR: 47z oe9i�/�F2 �ila�G Pemut Nu ober(Agency use only) 473. Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. UPCF hwfwrab(1/99)-3/4 http://www.unidm&org Rev.02/16/00