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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 N.PIPING CONSTRUCTION(CMrk NfMf WPM - ABOVEGROUND PIPING UNDERGROUND PIPING E./ ❑ 2. SUCTION ❑ S. GRAVITY SYSTEM TYPE ❑ 2. SUCT ❑ 0. GRAVITY l.9 t PRESSURE L7 1. PRESSURE ION � [3 85 � OTMER OI,fSINGLE WALL .UNKNOVM ' CONSTRUCTION (] 1 SINGLE WALL ❑�/g�LINEO TRENCH 0 2. DOUBLEWALL (3 W.OTHER MANUFACTURER L{2, DOUBLEWALL IC 85. UNIQI MANUFACTURER MANUFACTURER 8/. FRP COMPATIBLEWI IN%METHANOL ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE WI 100%METMNOL ❑ 1.BARE STEEL Qq GALVANIZED STEEL MATERIALS ❑ 2. STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ Z.STAINLESS STEEL N3 OTHER FLMSUE CORRASION ❑ STIC COMPATIBLE CONTENTS ❑95. UNKNOWN ❑ 9. PLASTIC COMPATIBLE WITH CONTENTS ❑ B. CATHODIC PROTECTION PROTECTION ❑ B. CATHODIC PROTECTION 4. FIBERGLASS ❑ S. FLEXIBLE(HOPE) ❑89.OTHER ❑ 4. FIBERGLASS []g5. UNKNOWN ❑ 5.BTEEL WICOATING [j 9. CATHODIC PROTECTION ❑ 5, STEELWICOATING hi:PIPING LEAK DETECTION(Check aO Met apPM ABOVEGROUND PIPING UNDERGROUND PIPING SINGLE WALL PIPING SINGLEWALLPIPING PRESSURIZED PIPING(CINck eN f fapply): MST PRESSURIZED PIPING(CMck aN fMf apnM: [] 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TESTWITH AUTO PUMP SHUT OFF FOR ❑ 1' SY�ST MOFAILURE.ADS SYSTEM OONNECTION'AUDI E AND VISUAL ALARMS R LEAN. LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION r AUDIBLE AND VISUAL 0 2 MONTHLY 0.2 GPM TEST ALARMS ❑ 22.MONTHLY 03 GPM TEST UPI�ANNUAL INTEGRITY TEST(0.1 GPM 3'J.ANNUAL INTEGRITY TEST(a 1 GPM) LT L DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(CMck aN metaPpH: CONVENTIONALSUCTION SYSTEMS: [] 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5, DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY ❑ 8 TRIENNIALINTEGRITYTEST(SAGPM) TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ T.SELF MONITORING ❑ 7,SELF MONITORING GRAVITY FLOW(Check N Met apPM: GRAVITY FLOW ❑ RING e. BIENNIAL INTEGRITY TEST IS 1 GPM) ❑ 9, DAILY ASU INTEGRITY TEST ❑ 8.BIENNIAL INTEGRITY TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(CAeck eN that app M: PRESSURIZED PIPING(CMck aN Mat appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Nark pMl (CMck Om) 0 .,AUTO PUMP SHUT OFF MEN A LEAK OCCURS ❑ e,AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ S AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION ,..,/aISCONNECTION LTc 'ND AUTO PUMP SHUT OFF L]c NO AUTO PUMP SHUT OFF ,.., 11. AUTOMATIC LINE LEAK DETECTOR(0.0 GPM TEST)WITH FLOW SHUT OFF OR L�T11.AUTOMATIC LEAK DETECTOR RESTRICTION [1-0.ANNUAL INTEGRITY TEST(0.1 GPM) [�.ANNUAL INTEGRITY TEST(0A GPM) SVC NIGMVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: 10.CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS L3-rS CONTINUOUS SUMP SENSOR rAU01BLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(CMck aN Maf apply) EMERGENCY GENERATORS ONLY(CMck aN fMf appy) ❑ 14. CONTINUOUS SUMP SENSOR`MTHOUT AUTO PUMP SHUT OFF.AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR`MTHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(0.0 GPH TEST)WITHOUT FLOW SHUT OFF OR AUTOMATIC UNE LEAK DETECTOR(0.0 GPH TESTI RESTRICTION [1 18. ANNUALINTEGRITYTEST(DIGPM ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DULYVISUALCHECK ❑ 17. DAILYVISUAL CHECK VRI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR r AUDIBLE AND VISVALALARMS ❑ 5. TRENCHUNER/MONITORING ❑ 0. CONTINUOUS DISPENSER PAN SENSOR`MTH AUTO SHUT OFF FOR DISPENSER.AUDIBLE AND VISUAL ALARMS L3.c NONE UL OWNER/OPERATOR SIGNATURE I C.*MM McI,Mlmalion pmM MIN,M41Ia en0 M. w BIa MM Of mY yno wv SIGNATURE OF TO DATE 7/,?/gn NAME OF ONME EMT (pMr10 ��^ TITLE OF OWNERIOPEM 4� PMmk NuniMr(Fw Mcal uNa alM Pe„K Apvr "(Fwlxelus wAl9 Pemit EWirNbnOM(FwkaMlu»mY) Formerly SWRCS Form R CUPAFORM(4/99)