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�rVIFIED PROGRAM CONSOLIDATED FORT TANK: TAO%6540 PR#: PR0506538 FAC#: FA0007486 UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(C .tt met mplr) Pw59fs UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSHBKTOH El 1.SINGLE WALL 03.LINED TRENCH 099.OTHER 450 [3 1.SINGLE WALL El 95.UNKNOWN 462 ❑2.DOUBLE WALL EJ 95.UNKNOWN El 2.DOUBLE WALL E3 99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE w/IOGH METHANOL ❑ L BARE STEEL ❑ 6.FRP COMPATIBLE w/1005:METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLEW/CONTENTS ❑ 95.UNKNOWN ❑4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 164 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VE.PIPING LEAK DETECTION(Checkall then mpy)(A description ofthe mmhmnepro®emsluh be suh vouni mtle led therm y.7 UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 67 PRESSURIZED PIPING(Check all lbat app1Y): PRESSURIZED PIPING(Check all that apply): ❑ L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WIT I AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION'AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑2.MONTHLY 02 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.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 MONITORMG OF PUMPING SYSTEM+TRIE'NNIEAL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCFION SYSTEMS(NO VALUES IN BELOW GROUNDPIPINGk ❑ 7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW ❑ 9.BIENNLM.INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ 8.DAILY VISUAL MONITORING ❑ 9.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 ALARMS AND(Clavi ere) ALARMS AND(C7:ek arc) ❑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 ❑c.NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ❑ IL AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.I 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(Clrrk all tint apply) ❑ 14.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 ❑ I5.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW IsBUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIE.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED 1682.CONTINUOUS DISPENSER PAN SENSOR AND VISUAL ALARMS ❑ ❑ S.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IN.OWNERIOPERATOR SIGNATURE I certify that the of tion pmvidd hoein is nue antharvcue to meharofny kro lel , SIGNATURE OF O WNEWOPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 4n 47z Pernik Nimber(Fmlrolusemh) 473 Pont AMMM(Forbulucemly) 474 Pemut EViratim6etelFmleuluscmly) 475 PT0008903 EE0002768 12/31/2004 UPCF(12/99 revised)