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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANKS - TANK PAGE 2 TANKS VL PIPING CONST RUCTION cheekenO,. Page of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE S]1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 458 ❑1.PRESSURE 0 2. SUCTION 1-b]RMMON 0 L SINGLE WALL 0 3.LINED TRENCH ❑3.GRAVITY q59 �99.OTIB3R qbo ❑1.SINGLE WALL ❑95.UNKNOWN 462 MANUh'ACTtIRER 0 2.DOUBLE WALL 1195.UNKNOWN 0 2.DOUBLE WALL 1199.OTHER MANUFACTURER 461 MANUFACTURER_ 0 1.BARE STEEL 0 6.FRP COMPATIBLE whIlo% METHANUL 0 1.BARE STEEL ❑6.FRP COMPATIBLE W/loo.h1E1DANpLM �Qyr2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 Unmown Q 2. STAINLESS STEEL 0 7.GALVANIZED STEEL L?3.PLASTIC COMPATIBLE W/CONTENTS 0 99. Other 0 3. PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 099. OTHER 0 4.FIBERGLASS 0 8.FLEXIBLE(HDPE) Q 4. FIBERGLASS 119.CATHODIC PROTECTION 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION q6a 0 5. STEEL W/COATING 0 95.UNKNOWN 465 VIL PIPING LEAK DETECTIONcheekell met 1 pdeuri 'w erne monitorin m ahau be subminedromekW UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Cheek all thin apply): PRESSURIZED PIPING(Chaek a 0w apply): Q 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 0 I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 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. 0 2.MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST 0 3.ANNUAL INTEGRITY TEST(0.IGPH) 0 3.ANNUAL INTEGRITY TEST ELIGPM 0 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cheeka8 tM appy) 0 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) 0 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): 0 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) 0 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 0 7. SELF MONITORING Q 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply). 0 S. DAILY VISUAL MONITORING 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check a0 that apply): PRESSURIZED PIPING(Check all mm apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL }AALARMS AND(Cha&ane) ALARMS AND(Check ane) b a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION 0c. NO AUTO PUMP SHUT OFF 0c NO AUTO PUMP SHUT OFF 011. AUTOMATIC LINE LEAK DETECTOR LIT)GPH TEST)WITH FLOW SHUT 011. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(0.1 GPM SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM Q 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 0 13. CONTINUOUS SUMP SENSOR,AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cheek au mat apply) EMERGENCY GENERATORS ONLY(Chmk all that apply) OU. CONTINUOUSSUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW 015. AUTOMATIC LINE LEAK DETECTOR 3'0 GPH TEST SHUT OFF OR RESTRICTION ( ) 0 16.ANNUAL INTEGRITY TEST(0.1 GPM 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK VOL DISPENSER CONTAINMENT DISPENSER CONTAINMENT 0 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK DATE INSTALLED 468 [R2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 5.TRENCH LINER/MONITORING 2001 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1 certify mat the inf¢tion oni ecl hcan is true and accurate m me best ofmy know)edge. SIGNATURE OF OWNER/OPERATOR DATE no NAME OF OWNER/OPRATOR(print) 471 1 TITLE OFOWNER/OPERATOR 4n Penna Number(Forloalummly) 473 Permit AppmvM(Forlocaluwmly) 474 Permit Expiration Daw(For local use only) 475 ....a. ..r.i /All��0/