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TANK: TA0202004 Noe i1FIED PROGRAM CONSOLIDATED FORM PR#: PR0232020 FAC#: FA0003767 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Cnak A Na W10 Page 3 of 5 UNDERGROUND PIPING ABOVEGROUND PIPING 159 SYSTEM TYPE ❑ 1.PRESSURE M 2.SUCTION ❑ 3.GRAVITY 458 E] I.PRESSURE ❑ 2.SUCTION E] 3.GRAVITY CONSTRUCTION [j 1.SINGLE WALL E13.LINED TRENCH F-1 99.OTHER 460 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 42 M 2.DOUBLE WALL ❑95.UNKNOWNEl2.DOUBLE WALL ❑ 99.OTHER "3 461 MANUFACTURER MANUFACTURER ❑ L BARE STEEL ❑6.FRP COMPATIBLE W I WM METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w11O A METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL [-17.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS [195.UNKNOWN ®4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 164 [15.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 469 VD.PIPING LEAK DETECTION(Chak all Na appy)(AmRipuoa of0 moaama pmgam 5MII eammiaM w kcal a,cacy.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 167 PRESSURIZED PIPING(Check a8 that apply): PRESSURIZED PIPING(Check all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W RH AUTO PUMP SENT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION'AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 9.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ® 7.SELF MONITORING ❑ ].SELF MONITORING GRAVITY FLOW ❑9.BIENNIAL INTEGRITY TEST(0.0 GPH GRAVITY FLOW(Check a6 that apply): ❑ 8.DAILY VISUAL MONITORING ❑ 9.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 ALARMSAND(Q aa) ALARMS AND(Chale ais) ❑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❑ DISCONNECTION 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 ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.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(Chxk all mat apply) EMERGENCY GENERATORS ONLY(Chaleallt tapply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.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 ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ SHUT OFF OR RESTRICTION SHUT OFF ORRESTNCTION ❑ 16.ANNUAL INTEGRITY TEST(0.I GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.I GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VRI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER/OPERATOR SIGNATURE I ratify mat mf a PorNee Memu auc aM a a a ate m ma hal ofmy lmovle* SIGNATURE OF OWNER/OPERATOR DATE 670 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 472 GREG RATIO 471 PttmitNaasa(Forloalaeo*) 473 Permit AM-M(FarM Ia eoay) 474 Pe t EViatioa Dam(Fa local a o*) 475 PT0004661 EE0000817 12/31/2000 UPCF(12/99 revised) `/ `�