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( 3v IFIED PROGRAM CONSOLIDATED FO I u s(1-'tloq TANKS l UNDERGROUND STORAGE TANKS -TANK PAGE 2 Pae of VI.PIPING CONSTRUCTION(Check dl that I UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION [13.GRAVITY 458. [11.PRESSURE ❑2.SUCTION [13.GRAVITY 459. CONSTRUCTION/ 1.SINGLE WALL [13.LINED TRENCH ❑99.OTHER W. ❑1.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER ®2 DOUBLE WALL ❑95.UNKNOWN [12.DOUBLE WALL ❑99.OTHER MANUFACTURER Smith Fibercast 461. MANUFACTURER 463. ❑1.BARE STEEL [16.FRP COMPATIBLE WIIWI.METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL D 3.PLASTIC COMPATIBLE WITH CONTENTS [195.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) [199.OTHER ®4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER [14.FIBERGLASS ❑9.CATHODIC PROTECTION [15.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION(Check all dus apply)(A d®c dan ofine anonusiag pmF=mall be submitosi to the low a enc) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 49. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST}} M ALTO PUNT 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. ❑2. MONTHLY 0.2 GPH TEST [12. 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+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUNTING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [36. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELFMONTIORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING [19. 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 ALARMS AND(Check one) ALARMS AND(Check one) ®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 [3c. NO AUTO PUMP SFIUT OFF []c. NO AUTO PUMP SHUT OFF 29 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 11 AUTOMATIC LEAK DETECTOR r.d OFF OR RESTRICTION W 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. CONTINUOUS SUNUP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [314. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUNT SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [315. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW [115.AUTOMATIC LINE LEAK DETECTOR 0.0 GPH TEST) SHUT OFF OR RESTRICTION []16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK [117. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED []2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15. TRENCH/LINER MONITORING 200cd 29 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [3 6. NONE y DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE I certify ormmion provide e a accurate to the best of my knowledge. SIGNATURE F O E OPERA OR DATEv 2 2� 470. NAME O 'ER/OPERATOR(prinQo Dennis Bock TFD.EOFOWNER/OPERATOR: Environmental Compliance ManagetRR' Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. 1 Pemut Exphation Date(Agency use only) 475. UPCF hwfwrc-b(1/99)-3/4 www.unidocs.org Rev.02/16/00