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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Tee P e of VLFD4ING COkYS`kRtUCTION ca�ta�� UNDERGROUND PIPING I :ABOVEGROUND PIPING SYSTEM TYPE ❑ 1.PRESSURE ❑2.SUCTION [13.GRAVITY 459. ❑1.PRESSURE ❑2 SUCTION ❑3.GRAVITY 459. CONSIRUCRONI 0 L SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 4W. ❑L SINGLE WALL MANUFACTURER [195.UNKNOWN 492, ❑z noIIBLE wA77 ❑95.uNxivowN ❑z.DOUBLE WALL ❑99,oTIIBR MANUFACTURER 461. MANUFACTURER 40. ❑1.HARE STEEL [16.PEP COMPATIBLE W1100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVAN¢EO STEEL ❑Z STAINLESS STEEL ❑7.GALVAN®STEEL ❑3.PLASTIC COMPATTBLE WITH CONTENTS ❑95.UNKNOWN [:13.PLASTIC COMPATIBLE W/CONTENTS ❑L F7 rnnar E(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑S.FLEXIBLE(HDPE) [199.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 44. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. �YEE PPEhiQ'DETH ,•6an3xui. s�,-n .» � ,r ..u,,.a- UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING W. SINGLE WALL PIPING 467. PRESSURIZED PIING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [11. ELECTRONIC LINE LEAK DETECTOR 3.0 GEE TEST WITH AUTO POMP 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. ❑I MONTHLY 0.2 GPH TEST ❑Z MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) [34. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [35.INTEGRITY TEST(0.1 GPH) 5. DAILY VISUAL MONITORINGOF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING).' C16. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEM(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [3 7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Cheek all the apply): [38. DAILY VISUAL MONITORING ❑9. BIENNIAL.INTEGRITY TEST(0.1 GPH) SECONDARD.Y CONTAINED PIPING SECONDARD.Y CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all Won apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Cheek one) ALARMS AND(Cheek one) ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO POMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Q. NO AUTO PUMP SHUT OFF E3e. NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC I24E LEAK DtrECTOR(3.0 GPH TEST)µms{FLAW SHUT 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVTrY SYSTEM SUCITON/GRAVTTY 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(Cheek all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW [3 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TFST(0.1 GPM ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUALCIIECK -. VIM DISPENSER CONTAINI ERP![ 79 DISPENSER CONTAINMENT 469. ❑1. FLOAT MECHANISM THAT SHUTS GEF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED [:12. CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/IINFA MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER I AUDIBLE AND VISUAL ALARMS C]ti. NONE I certify that the infonoatlan provided herein is tme and accurate In the beat of my knowledge. SIGNATURE OF O ER/OP DATE: /a �4� 470. I / NAME OF OWNER/OPERATOR(pint): )/el f�0 St'lln (vtaia TITLE OF OWNER/OPERATOR: 4M Permit Ntmbc(Agency,00e only) l 47I. I Pekmit Appmwd By(Agency we only) 474. 1 Pekmit Eapindiaa Deka(AgcecY a c Only) s75. UPCF hwfwrc-0(1199)-314 httpd/w .midomorg Rev.02/16/00