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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION(Chuck NMat appy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION V4 GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ T SINGLE WALL ❑ 3. LINEDTRENCH ❑99. OTHER ❑ 1. SINGLE WALL 1195. UNKNOWN MANUFACTURER ❑ 2 DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL 1199. OTHER MANUFACTURER MANUFACTURER BARE STEEL ❑ 8. fRP COMPATIBLE WI 1W%METHANOL ❑ 1. BARE STEEL ❑ B. FRP COMPATIBLE WI 100%METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTICCOMPATIBLEWITHCONTENTS 13 95 UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. FLE%IBLE(HOPE) C3. OTHER ❑ 4. FIBERGLASS ❑ B. FLEXIBLE(HOPE) 11 W, OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WI COATING ❑ 9. CATHODIC PROTECTION ID 5. STEEL WI COATING 1195, UNKNOWN VII.PIPING LEAK DETECTION(Check N Mx appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING [/' SINGLE WALL PIPING PRESSURIZED PIPING(Chack 0that apples: "T PRESSURIZED PIPING(CMI as that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST NTH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST NTH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION-AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION Z AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 02 GPM TEST 11Z. MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0 1 GPM) ❑ ]. ANNUAL INTEGRITY TEST(0,1 GPM) 11 <. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check as that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST to 1 GPM) ❑ B. TRIENNIAL INTEGRITY TEST(I GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)'. ❑ T. SELF MONITORING ❑ T. SELF MONITORING GRAVITY FLOW. GRAVITY FLOW(Check an that appy): ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNMLINTEGRITYTEST(OAGPI) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check aN that appy): PRESSURIZED PIPING(Check as Mal appy): 10. CONTINUOUS TURBINE SUMP SENSOR HATHAUDIBLE AND VISUAL ALARMS AND (Chaps one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(track one? ❑ c AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ D AUTO PUMP SHUTOFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION C1D, AUTO PUMP SHUTOFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ C. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ❑ 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TESTI NTH FLOW SHUT OFF OR ❑ 11, AUTOMATICLEAKDETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTtOWGRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check as Mat appy) EMERGENCY GENERATORS ONLY(Check aH that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18.ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ ti. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VM.DISPENSER CONTAINMENT DISPENSERCONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILYVISUALCHECK DATEINSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING ❑ 1 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS 8. NONE IX.OWNERIOPERATOR SIGNATURE I ceNy Nal Na Mlarmatipn pmviEeE heroin is Wa IIIexrata uip the beat DI my knwAe09a. SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNERIOPERATOR(Wm0 TITLE OF OWNER,OPERATOR Penh NwnSar(Forbcal uas orvy) P...t Ave pPraE(For laN oaa oft) PamYt ExpraSen Data(Fprks al use wdy) CUPAFORM(4/99) x- -� Formerly SVIRCB Form B