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IFIED PROGRAM CONSOLIDATED FOR O7 1470(c7 9� n( v� TANKS UNDERGROUND STORAGE TANKS -TANK PAGE IS;- ell Pape of VI.PIPING CONSTRUCTION(Check an that appy) UNDERGROUND (PING ABOVEGROUND PIPING SYSTEM TYPE It-.)l. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTIOfU 1. SINGLE WPL ❑ 3. LINEDTRENCH ❑99. OTHER ❑ I. SINGLE WALL ❑95. UNKNOWN MANUFACTUR :.)21 DOUBLE WAL NKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER Western"Ma"ass MANUFACTURER ❑ 1.BARE STEEL . FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE WI 100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION ORRROSI ON ❑ 3. PLASTICCOMPATI%E ITH COMENTS 095. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 0. FLEXIBLE(HOPE) W. OTHER PROTEC ❑ 4. FIBERGLASS FLEXIBLE(HDPE) ❑W. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5.STEEL W/COATING % 9. CATHODIC PROTECTION 10 5. STEELWICOATING El 95. UNKNOWN VII.PIPING LEAK DETECTION(Check all mat appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALLPIPING SINGLE WALL PIPING 1 P SSURIZED PIPING(Check all Nal apply): PRESSURIZED PIPING(Ched all that apply): jjb_ECTRONIC LINE LEAH DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAH, LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISU,A.ALARMS 1 q��LAARMS ❑ 2. MONTHLY 0.2 GPH TEST ONTHLY 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 MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ T SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW(Chad all Mal apply): ❑ 9. BIENNIALINTEGRITYTEST(OAGPH) ❑ B, DAILYVISUALMONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Chea all that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check are) Greck one) ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION OFF FOR LEAI4S,SYSTEM FAILURE AND SYSTEM ❑ b. AUTO PIR.1P SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION c. ND AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHAT OFF X 1. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAH DETECTOR RESTRICTION 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST(O.1 GPH) SUCTIONIGRAVRY SYSTEM: SUCTIOWGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUALALARMS EMERGENCY GENERATORS ONLY(Check all Nal appy) EMERGENCY GENERATORS ONLY(Cheri all Thal ajaI ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC LINE LEA)(DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16. ANNUAL INTEGRITY TOT(0.1 GPH) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILYVISUALCHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK 1 NSTALLED 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ S. TRENCH UNERI MONITORING 2001 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ B. NONE DL OWNERIOPERATOR SIGNATURE I ceNfy mat Ne Intoimation aovided IhAl A tme and accurate to the best 0 my knowledge. SIGNATURE OF OWNERIOPERATO DATE October 25,2007 NAME OF OWNERIOPERATOR(pae0 TITLE OF OWNERIOPERATOR Butch Hobson Safety and Environmental ABalrs Manager Permit Number(Fprbcal use ppy) Permit Appmved lPo klcal use.ly) Pelmlt Expiration Date(Farb Mae only) CUPAFORM(4199) Formerly SW RCB Form B