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UNIFIED PROGRAM CONSOLIDATED FORM ` TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(ClXack YflW apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION GMV?Y ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑N. OTHER ❑ 1. SINGLE WALL ❑N. UNKNOWN MANUFACTURER ❑ 2. DOUBLE WALL 1195 UNKNOWN ❑ 2. DOUBLE WALL [IN. OTHER MANUFACTURER MANUFACTURER 1 BARE STEEL ❑ B. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ S. FRP COMPATIBLE W1 IW%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T.GALVANIZEDSTEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95 UNKNOWN ❑ 9. PLASTIC COMPATIBLE WITH CONTENTS ❑ B FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. FLEXIBLE(HDPE) 1199 OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING 095. UNKNOWN WL PIPING LEAK DETECTION(CMdk a,at appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL%PING PRESSURIZED PIPING(Check A9 Mat apply)r PRESSURIZED PIPING(Check aA tMt apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST VATH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK.SYSTEM FAILURE,AND SYSTEM DISCONNECTION-AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS 112. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 02 GPH TEST ❑ ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH)]. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS'. CONVENTIONAL SUCTION SYSTEMS(C kW tMt apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST 10.1 GPH) ❑ 8. 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. SELFMDNITORING ❑ T. SELFMONITORING G VITY FLOW yn A )� GRAVITYFLOW(Ch .,,MMapply): 9. BIENNIAL INTEGRITY TEST(011 GPH) Q 1 I"ri�I TQr e� ❑ S. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY MST(01 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(DMck 4 MN appy): PRESSURIZED PIPING(Check all that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (CMck ma) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(tl Ix*me) ❑ a. AUTO PUMP SHUT OFF MEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e AUTO PUMP DISCONNECTION OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ 5, AUTO PUMP SHUT OFF 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 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/ORAVITY SYSTEMSUCTIOWGRAVITY SYSTEM'. ❑ 13. CONTINUOUS SUMP SENSOR I AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUOIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check a that appy) EMERGENCY GENERATORS ONLY(Ch kaS But appy) ❑ 11. CONTINUOUS SUMP SENSOR WITIIOUTAUTO PUMP SHUT OFF.AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL VISUALAURMS ALARMS ❑ 15 AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOWSHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 1S. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17. DAILYVISUALCHECK ❑ tT. DAILY VISUALCHECK VBL DISPENSERCONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOATMECHANISM THATSHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK DATEI STALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUALALARMS ❑ S TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS . NONE IX OWNER/OPERATOR SIGNATURE 1 r mN Vlat 9Xe inPonna9Pn POaWed heroin is true aM BCCVrata to W peat IN my kllPaledpe. SIGNATUREOFOWNERIOPERATOR DATE NAME OF OWNER/OPERATOR OMKI TRE OF OWNER/OPEILITOR Permit Numher(Forbpl uas a+a/9 PomlKAppmvad(Fwbpl uae Doty) Pemla Eapkalgn DaOa lFPrracW use arlA') CUPAFORM(4199) `/ e00 Formerly SWRCS Form 8