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IFIED PROGRAM CONSOLIDATED FO L <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 Pa e of <br /> VI.PIPING CONSTRUCTION(Chwk all that I) ABOVEGROUND PIPING <br /> UNDERGROUND PIPING 459. <br /> SYSTEM TYPE ®1.PRESSURE [12.SUCTION [13.GRAVITY 458. ❑1.PRESSURE D 2.SUCTION ❑3.GRAVITY 463. <br /> CONSTRUCTION/ D 1.SINGLE WALL [013.LINED TRENCH ❑99.OTHER 460. D 1.SINGLE WALL D 95.UNKNOWN <br /> MANUFACTURER ®2 DOUBLE WALL D 95.UNKNOWN D 2.DOUBLE WALL D 99.OTHER <br /> 461. MANUFACTURER 463. <br /> MANUFACTURER Smith Fibercast BARE STEEL [3 6.FRP COMPATIBLE W/100%METHANOL <br /> [11.BARE STEEL D 6.FRP COMPATIBLE W/100%METHANOL D 2.STAINLESS STEEL D 7.GALVANIZED STEEL <br /> 2.STAINLESS STEEL [17.GALVANIZED STEEL <br /> D 3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN El 3.PLASTIC COMPATIBLE W/CONTENTS 0 9 CATHODIC PROTECTION ❑99 . <br /> OTHER <br /> D <br /> ®4.FIBERGLASS D S.FLEXIBLE(HDPE) D 99.OTHER [14.FIBERGLASS E3 95.UNKNOWN 464. 465. <br /> ❑$.STEEL W/COATING 09.CATHODIC PROTECTION D 5.STEEL W/COATING ehellbesubmitted to the laml mcJ <br /> VD.PIPING LEAK DETECTION(Checkaathata 1)(Adend onofthemonitmin ABOVEGROUND PIPING <br /> UNDERGROUND PIPING 467. <br /> SINGLE WALL PIPING 466. SINGLE WALL PIPING <br /> PRESSURIZED PIPING(Check all that apply): <br /> PRESSURIZED PIPING(Check all that apply): <br /> D 01. ELECTRONIC <br /> SYGEUAUTO PUNT <br /> ELECTRONIC LINE <br /> SSDETECTOR 3.0 GPH TEST AND SYSTEM DISCONNECTION <br /> AND SYSTEM SCONNECTION HUT OFF FOR LEAK, STEM FAIL <br /> SHUT-OFF FOR LEAK, TEM FAILURE, <br /> +AUDIBLE AND VISUAL ALARMS. <br /> +AUDIBLE AND VISUAL ALARMS. 02. MONTHLY 0.2 GPH TEST <br /> D 2. MONTHLY 0.2 GPH TEST <br /> 03, ANNUAL INTEGRITY TEST(o.t GPH) <br /> [13. ANNUAL INTEGRITY TEST(0.1 GPH) D q DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING D 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION O SYNNIAL STEMS(140 VALVES IN BELOW GROUND PIPING): <br /> [37. SELF MONITORING <br /> ❑7. SELF MONITORING <br /> GRAVITY FLOW <br /> GRAVITY FLOW(Check all that apply): <br /> [39. BIENNIAL INTEGRITY TEST(0.1 GPH) []8. DAILY VISUAL MONITORING <br /> D 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING <br /> SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): <br /> PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR W17' AUDIBLE AND VISUAL 10. CONTINUOUS <br /> ANDD(Check o E)SUMP SINSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) <br /> ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ®a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> AUTO PUMP®b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM D b. DISCONNECTION <br /> _OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION <br /> Dc. NO AUTO PUMP SHUT OFF <br /> Dc. NO AUTO PUMP SHUT OFF <br /> ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT D 11 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> ®12. ANNUAL INTEGRITY TEST(0.1 GPH) S 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTIONIGRAVITY SYSTEM <br /> SUCTION/GRAVITY SYSTEM OUS _ <br /> D 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS D EMERGENCY GENE ORS ONLY(ChecSENSOR+ k AND <br /> all thatNa Pty)SUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) <br /> D 14. CONTINUOUS SUMP SENSOR WITH U7 AUTO PUMP SHUT OFF [314. CCOONNTI ODUSDSUMP SSENVISUALNSSOARMSTHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS <br /> D 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW D 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> D 16. ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> Q 17. DAILY VISUAL CHECK 1D 17.DAILY VISUAL CHECK <br /> Vin.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 468. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [34, DAILY VISUAL CHECK 469. <br /> DATE INSTALLED 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15. TRENCH/LINER MONITORING <br /> 7 yw 993. CONTINUOUS DISPENSER PAN SENSOR WIrH AUTO SHUT OFF FOR D 6. NONE <br /> !iW D DISPENSER+AUDIBLE AND VISUAL <br /> IX.OWNERIOPERATOR SIGNATURE <br /> I certify that t [marten provided d accurate to the best of my knowledge. 470 <br /> SIGNATURE TOWN O RAT DATE: a 7� <br /> TITLE OFOWNER/OPERATOR: Environmental Compliance NanageP" <br /> NAME OF R/ ERATOR(prin0c Dennis BOCk <br /> Permit Number(Agency use only) <br /> 473, 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 475. <br /> UPCF hwfwrc-b(1/99)-3/4 <br /> www.unidocs.org Rev.02/16/00 <br />