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UNIFIED PROGRAM CONSOLIDATED FORM 4 TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING,CONSTRUCTION Oi«kiii,th,t I Pae of UNDERGROUND PIPING SYSTEM TYPE ❑1.PRESSURE 2.SUCTION ABOVEGROUND PIPING CONSTRUCTION/ I.SINGLE WALL ),GRAVITY 45i. ❑1.PRESSURE 2.SUCTION ❑3.GRAVITY 459, MANUFACTURER 03.LINED TRENCH 099.OTHER 460. 0-LSINGLEWALL AN DOUBLE WALL 095.UNKNOWN 0 95.UNKNOWN MAN461 UFACTURER ❑2.DOUBLE WALL ❑99,OTHER ARE STEEL 461' MANUFACTURER ❑6.FRP COMPATIBLE W/100%METHANOL ❑L BRAE STEEL 463' 0 2.STAINLESS STEEL 0 7,GALVANIZED STEEL [16.FRP COMPATIBLE W/100%METHANOL 0 ❑95.UNKNOWN El 3.PLASTIC COMPATIBLE W/CO 1 PLASTIC COMPATIBLE WITH CONTENTS 0 2.STAINLESS STEEL NTENTS 0 8.FLEXIBLE(HDPE) 0 99.OTHER 0 7.GALVANIZED STEEL ❑4.FIBERGLASS ❑e.FLEXIBLE(HDPE) ❑99.OTHER ❑4FIBERGLASS 0 ,5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464. 0 9.CATHODIC PROTECTION ❑5 STEEL RCOATING 1-195.UNKNO Wry VTI.PIPWGliEAK DETECPION Cn«k.gin'a 7 Ad<arxf roa n „mmd� .mr.minarns<sat cram maid=.1<<nar. 465. IINDERGROVND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING ABOVEGROUND PIPING PRESSURIZED PIPING(Check all that apply): 467 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W PRESSURIZED PIPING(Check all that apply): SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM_WITH 0 1, ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP +AUDIBLE AND VISUAL ALARMS, SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION 02. MONTHLY 0.2 GPH TEST +AUDIBLE AND VISUAL ALARMS, PH TEST 03. ANNUAL INTEGRITY TEST(0.I GPH) 02. MONTHLYNUAINT0.2 GRITYTE / 03. ANNUAL INTEGRITY TEST(0.1 GPH) CONVENTIONAL SUCTION SYMMS 04, DAILY VISUAL CHECK 0 S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING CONVENTIONAL SUCTION SYSTEhIS(Check all rhu apply) INTEGRITY TEST(0,1 GPH) CIS. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [17. SELF MONITORING ❑6. TRIENNIAL INTEGRITY i1ST(0.1 GPH) GRAVITY FLOW SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 07. SELFMONITORING 09. BIENNIAL INTEGRITY TEST(O.I GPH) GRAVITY FLOW(Check all that apply): 0 S. DAILY AL INT MONITORING SECONDARILY CONTAINED PIPING /+j 09' BIENNIAL INTEGRITY TEST(0.1 GPH) / SECONDARILY CONTAINED PIPING PRESSURIZED PIPING G(Check all That apply): 10. l that apply): CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL OCONTINUOUS TURBINEPRESSURIZED PIPING SUMPCheck SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ALARMS AND(Check one) 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM(FAILURE AND SYSTEM Cl.. NO AUTO PUMP SHUT OFF DISCONNECTION 1111. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT Ck NO AUTO POMP SHUT OFF OFF OR RESTRICTION 0 11.AUTOMATIC LEAK DETECTOR 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013, CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ E GENTINUOUS SUMP CYGENERATORS NSOR+ONLY AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF 014. CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS 0WITHOUT AUTO PUMP SHUT OFF 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW AUDIBLE AND VISUAL ALARM SHUT OFF OR RESTRICTION C]15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) 016. ANNUAL INTEGRITY TEST(0.1 GPH) [116 ANNUAL INTEGRITY TEST(0.1 GPH) 017, DAILY VISUAL CHECK 017 DAILY VISUAL CHECK VIII.DISPENSER.CONT9TNhIENT DISPENSER CONT 464. 01. FLOAT MECHANISM THAT SHUTS OFFS VALVE mow//�}F DATTE)INSTALL '_E//Dj /f 02. CONTINUOUS DISPENSER PAN SENSOR HE VALBLE AND VISU ALARMS 09. DAILY VISUAL CHECK 469. (/ frWN 03. CONTINUOUS DISPENSER PAN SENSOR W CI 5. TRENCH/CHER MONITORING _� AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS 06. NONE L`C.OsVNER/OPERATORSjGNATURE I certify tha the information provided herein is true and accurate to the best oCmy knowledge. SIG OF OWNER/OPERATOR DATE: r/ 0 NAME 1YNER/OP .4TOR( ' t: _ o TITLE OF ERA Y 472. 'rC� Pmum ni1 Nbcr(Agency use only) 471 Pemu1 Approved BY(Agency use n1y) 474. emtit Ex tion D (Agency uaa only) 475. Pira UPCF hwfwrc-b(1199).314 http://www.unidocsorg Rev.02/14/00