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,. .NIFIED PROGRAM CONSOLIDATED FORMTANK: TA02020013 U/Id" ✓':� f, 1C, PRO: PRO232020 UNDERGROUND STORAGE TANKS - TANK PAGE 2 FAC M: FA0003767 VI.PIPINGCONSTRUCTION(clack PnI t,,,,y) fyF3ors LNDER(HLO NO PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1.MIKIISVRF 2.SUCTION ❑3.GmvrTY 456 ❑ I.PRESSURE ❑ 2.SUCTION ❑t.GRAVITY 439 CONSTIIIRO(M ❑1.5.SINGLE WALL [13.3.LINED TRENCH [199.OTHER 46a 0 I.SINGI.F WALT. 0 95.UNKNOWN 40 M�DOUBLEWALL ❑95.UNKNOWN L3 2.DOUBLE WALL ❑99.OTHER MANUFACTURER 401 MANUFACTURER 461 ❑ L bAKE STEEL ❑6.PRP COMPATIBLE w Il M[TRMOL ❑ I.RARE,STP.RT. ❑6.FRP COMPATIBLE w loon McTRANDI. ❑2.SrAINLESSSTEEL ❑7.GALVAN17ED STEEL ❑2.STAINLESS STEEL ❑T.GALVANIZEDSTF.P.L MASTIC LAMPATIBLEWICONTENTS ❑ 95.UNKNOWN C] PLASTIC COMPATDII.P.W1 CONTENTS. ❑95.UNKNOWN iri/FIRERGV$S ❑S.FLEXIBLE fHOPE) ❑M.OTHP.R ❑4.POERGLASS [I S.FLEXIBLE(HDPE) ❑99.OTHER ❑S.STEEL W/COATING ❑9.CATHODIC PROTECTION 4M ❑5.STEEL WK'OATING ❑ 9.CATHODIC PROTECTION µq VR.PIPING LEAK]BETE M. ON(Chkei da SNIIJ(A P7d...Mwino maaaa shall hm6 P,1016k 1-1 UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPNC 4aa SINGLE WALL PIPING, 467 PRESSURIZED PIPING(Cheek an INat aPPIO: PRnAUhIZED PIPING(Cheek e1 that applyk ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W TTM AUTO PUMP SHAT OFP ❑ I.RLECTRONUC LME LEAK DETECTOR 3.0 GPM TEST WITH AU'T'O PUMP SHAT OFF FOR LEAK.SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LPAK,SYS TEM FAILURE AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL.ALARMS. VISUAL ALARMS. [12.MONTHLY 0.2 GPM TEST ❑ 2.MONTHLY 02 OPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑3.ANNUAL.INTPf.Rr TEST(0.1 OPH) ❑d.DAILY VI411AL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(CDeck all that epPFF) ❑ S.DAILYVIRUALMOMTORINOOFPUMPMGSYSTPM+TRIENNIEAL PIPING ❑5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ,,,,INTEGRITY TEST(0.1 GPM ❑ 6.TRIENNIAL INTEURIT'TY TES (0.1 GPM) SA74CT1ON SYSTEMS(No VALUES IN%CLOW GROUNDPIPINC): SAFE SUCTION SYSTEMS(NO VMAIRS IN RPLOW GROUNDPIPING): 7.SELF MONITORING ❑ 7.FP2.P MONITORMO GRAVITY PROW ❑9.BIENNIAL INTEGRITY TEST(0.1)GPX GRAVITY FLOW(Check all that apply): ❑ S.DAILYVISUALMONITORTNO ❑9,BIENNIAL INTPORITY TEST(0.1)UPM SECONDARILV CONTATNF.D PIPING SECONOAMIN C.ONTAFNCD PIPING PRGVURILED PIPING(Cheek all that Apply); PRESSURIEPD PIPING(Check 611 tbal aPPIyY 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS ANDmkAkaa) ALARMS AND(C ackane ❑a.AUTO PUMP Slur OFF WHEN A LEAK OCCURS [:1 A.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO PUMP SHUT OFF FOR I.PAK9,SYSTEM FAILURE ANO SYSTEM E]DISSAUTOCCONNNECTIONINT OPF FOR LEAKS.SYSTEM FAILURE,AND SYSTEM DISCONNECTION ❑c.NO AUTO PUMP SHUT OFF ❑9.NO AUTO PLUMP SNIT OFF ❑ I I.AUTOMATIC LINE LEAK DF.TPCTOR D.0GPH TEST)WITH FLOW SUNT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(6,1 GFH) ❑ 12.ANNUAL.INTP.GRITY TEST(0.1 GPM SUCITORK:RAVrTY SYSTEM SUCPON/C:RAVITY SYSTEM ❑ 13.CONTINUOLSSUMPSENSOR*AUDIBLE.AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR IAUDIBLE AND VISUAL ALARMS EMF.Rc;NCY GENERATORS ONLY(OcAk el dal•PM RMFRCP.NCV GENERATORS ONLY(Thak nl dr qW ❑ 14.CONFMUOUS SUMP SENSOR W IT14OUr AUTO PUMP SHUT OPP• ❑ Il CONTINUOUS SUMP SENSOR WW AUTO PUMP SHUT OFP- AUDISLF,AND VISUAL ALARMS AUDIBLE.AND VISUAL ALARMS 15.AUTUMATIC LINE LPAK DBIECTOR(.LO GPM TEST)_y.133 U'j FLOW ❑ IS.AUTOMATIC LINE LEAK DETECTOR(3-n OPI TEST)WITHOUT FLOW ❑SUNT OFF OR RESTRICTION SHUT OFF OR RF_STRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 OPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17.DAILY VISUAL.CMECK ❑ t7.DAILYVISUALCHECK VIB.DISPHNSERCONFA NMMMI DISPENSER CONTAINMENT E] 1,FLOAT MP.CHANISM THATSMUTSOFF%HEARVALVE ❑4.DAILY VISUAL CHECK DATENSTALLED 4M I-9 ICONTINUOUS DISPENSER PAN RENSOR+AUDIBLE AND VISUAL ALARMS ❑5.TRENCH LINER I MONROMU ❑3.CONTINUOUS I'MSPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONP "a DISPENSP.R+AUDIBLE AND VISUAL ALARMS LTC.OWINERKIFEKA I UK OK&11ARTIRE I mXytla the bfwnNknnArvwAneelnb ma and ams+.aaePal ofgb..,. ao SIGNATTUREOPO PERATOR 7 DATE NAMSOFOWNER/OPERA R(Pint) m iITLF OF OWN OPEN/TO e.ly 471 Pnw AMTGYMWVTM11--mly) 479 MaM Ef-0Imlbn Dnle(Pnlwllwemyl 473 PT0 Pan0466 12131./2002 7000A661 £EOOooat7 UPCF(12/99 revised)