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%. ..r UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pa e 2 of 2 VI.PIPING CONSTRUCTION(Check tll tnat b9 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® I.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 1 ® I.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ O 1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑L SINGLE WALL ❑95.UNKNOWN del. MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ®2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463. ❑I.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL ❑I.BARE STEEL O 6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL EI 7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑S.FLEXIBLE(HDPE) ❑99.OTHER ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ®4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 46a. ❑5.STEEL W/COATING [195.UNKNOWN 465. VIL PIPING LEAK DETECTION(Check dl that sN,10(A encri 'on orthe Monitorin ovn shall rte sutanae4 to the local UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10 L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WIT Tl AUTO PUMP SHUT-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. ❑2. MONTHLY 0.2 GPH TEST [32. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) [14, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [15. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) GRAVITY FLOW [17. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [39. DAILY VISUAL MONITORING [39. 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(Check one) ALARMS AND(Check one) ®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 [1c. NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT E3 OFF OR RESTRICTION 11.AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPM) [112. ANNUAL INTEGRITY TEST(0.1 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(Check all that apply) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF ❑14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015, AUTOMATIC LINE LEAK DETECTOR (30 GPH TEST) WITHOUT FLOW ®I5. AUTOMATIC LINE LEAK DETECTOR 30 GPH TES SHUT OFF OR RESTRICTION ( ' T) [116. ANNUAL INTEGRITY TEST(0.1 GPH) [116. ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK [317, DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ®I. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15. TRENCH/LINER MONITORING [13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is Wrd accA2w tot st of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE:6/02/11 470 NAME OF OWNER/OPERATOR(pG I Ti6cICIng CODlpany TITLE OF OWNER/OPERATOR: Safety Manager 4n. Permit Number(Agency use only) 4]3. Permit Approved By(Agenry use only) 474 1 Permit Expiration Date(Agency use only) 475. UPCF hwrwrc-b(1/99)-3/4 http:/Avww.unidm.org Rev.02/16/00