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� A,a7IFIED PROGRAM CONSOLIDATED FORM TANK: TA0187202 ^ ,iT' Vttt� PR#: PR0231872 FAC#: FA0003967 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(On ck.E nut apply) Parc 3 ef3 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEMTYPE ❑ (.PRESSURE [12.SUCTION ❑3.GRAVITY 458 ❑ I.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 459 CONSTIt CD [:11.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 460 ❑ L SINGLE WALL ❑ 95.UNKNOWN 452 02.DOUBLEWALL ❑95.UNKNOWN ❑ 2.DOUBLE WALL ❑ 99.OTHER MANUFACTURER 461 MANUFACTURER 163 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/IM METHA 01. ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE w/1905 METHANOL ❑ 2.STAINLESS STEEL ❑Z GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ ".OTHER ❑ 5.STEEL W/COATING [19.CATHODIC PROTECTION 451 ❑ S.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 466 VD.PIPING LEAK DETECTION(Ona ml In,t,pplr)(A ae,cription orrla aucnmieaprolp,m:n,n 6c.a6milua m ue bcal,aemy.) UNDERGROUND PIPING ABOVEGROUND PIPMG SINGLE WALL PIPING 466 SINGLE WALL PIPING 457 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ ].ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT 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) ❑4.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(0.1)GPH GRAVITY FLOW(Check all 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 W ITH AUDIBLE AND VISUAL ALARMSAND(C me) ALARMSAND(Caskma) ❑ 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 ❑ 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(G ka8 that apply) EMERGENCY GENERATORS ONLY(ChN"ttat"Iy) ❑ 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)WITH FLOW ElM 15.AUTOMATIC LE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(O.I GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VDI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATEINSTALLED 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 1 ccrj4 huh ien um prov laaeia is Wca =e to to th bot ofnryl kd c SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 471 472 Pcmk NmNbcr(Fmkaalmemly) 473 P (AI,mv (Fml-alo only) 474 Pe ft Eapk,timO (For localr only) 475 PT0006679 EE0000817 12/31/2001 UPCF(12/99 revised)