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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 <br /> YL p-fPING CONST,RUCTIO,N cneok xtHhat I t Pee of <br /> UNDERGROUND PIPING <br /> FCONSTRM�NONJ <br /> ABOVEGROUND PIPING <br /> .PRESSURE J.SUCTION ❑3.GRAVITY 458. _�!.PRESSURE '?.SUCTION - 3.GRAVITY asq. <br /> .SINGLE WALL ❑3.LVED TRENCH 0 99.OTHER 460. <br /> MANUFACTURER �`I.SINGLE WALL 0 95.UNKNOWN 462. <br /> .DOUBLE WALL FI 95.UNKNOWN ..DOUBLE WALL <br /> MANUFACTURER 099.OTHER <br /> 461. MANUFACTURER <br /> ❑1.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL ti.BARE STEEL 463' <br /> 0 2.STAINLESS STEEL 0 7,GALVANIZED STEEL 6 116-FRP COMPATIBLE W/100%METHANOL <br /> 2.STAINLESS STEEL [17.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS <br /> 0 4.FIBERGLASS 9 8.FLEXIBLE(HDPE) 0 99.OTHER 0 8.FLEXIBLE(HDPE) C1 99,OTHER <br /> 0 5.STEEL W/CDATING 0 4.FIBERGLASS 0 9.CATHODIC PROTECTION <br /> ❑9.CATHODIC PROTECTION 461. 0 5.STEEL W/COATING ❑95.UNKNOWN <br /> Vll-PIPING LEAK D9 PCFION((..aka111hat11(A buaftM nanitgdn nm.twn be wbnktd mthe tical• ,( 465. <br /> UNDERGROUNDPIPNG <br /> SINGLE WALL PIPINGABOVEGROUND PIPING <br /> a66� SINGLE WALL PIPING <br /> 46q. <br /> PRESSURIZED PIPING(Check all that apply):pP Y): <br /> [I 1. ELECTRONIC LINE LEAK DETECTOR 3.0 CPH TEST WITH AUTO PUMP PRESSURIZED PIPING(Check all that apply): <br /> SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION [31. ELECTRONIC LINE LEAK DEFECTOR J.DRE GPH TEST WITH AUTO PUMP <br /> +AUDIBLE AND VISUAL ALARMS. SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> +AUDIBLE AND VISUAL ALARMS. <br /> 0 2. MONTHLY 0.2 GPH TEST [12, MONTHLY 0.2 GPH TEST <br /> 0 3. ANNUAL INTEGRITY TEST(D.1 GPH) 03. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that. I <br /> 0 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING pP Y) <br /> INTEGRITY TEST(0.1 GPH) SCS. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> 0 T SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW r7. SELFMONITORING <br /> [19. BIENNIAL INTEGRITY TEST(OfI G..^H) GRAVITY FLOW(Cheek all theta apply): <br /> Y <br /> Pill. DAILY VISUAL MONITORING <br /> 09. 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 pSENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check UT ALARMS AND(Check one) <br /> ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 b. AUTO PUMP SHAT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Uc. NO AUTO PUMP SHUT OFF Uc. NO ROTO PUMP SHUTOFF <br /> 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT <br /> OFF OR RESTRICTION 1111. AUTOMATIC LEAK DETECTOR <br /> 0 12. ANNUAL INTEGRITY TEST(0.1 OPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> A13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> ❑Il. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that a I <br /> ?1-14. CONTINUOUS SUMP SENSOR W THOUT AUTO PUMP SHUT OFF `S� PP Y) <br /> AUDIBLE AND VISUAL ALARMS z 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> 8115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW AUDIBLE AND VISUAL ALARMS <br /> SHUT OFF OR RESTRICTION " Q5. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> 016. ANNUAL INTEGRITY TEST(0.1 GPH) 0 16. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 17. DAILY VISUAL CHECK W7. DAILY VISUAL CHECK <br /> Vlll.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 468. [] 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE <br /> DATEINSTALLED 02, CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 09 TRENCHDAILY ILINERMSUAL ECK qbq, <br /> 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 05. TRENCPULINER MONITORING <br /> DISPENSER+AUDIBLE.AND VISUAL ALARMS 06. NONE <br /> IX OWNER/OPERATOR SIGNATURE <br /> 1 certify that the information provided herein is tore and accurate to the best of my knowledge. <br /> SIGNATURE OF OWNER/OPER R DATE: f1 <br /> - iD - 03 a19. <br /> NAME OF OWNER/OPERATOR(print3: /)� V, CN-1. -JJ TITLE OF OWNER/OPERATOR: 4 - art. <br /> Permit Number(Agency use only) 471. 1 Pcrmit Approved By(Agency use onl <br /> Y) 414. Permit ExpinlionD (Agency use only) +15 I <br /> UPCF hwfwrc-b(1199).3/4 httpy/www.unidocs.org <br /> Rev.02/16/110 <br /> 9 <br />