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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE Z Pae of VL PIPING CONSTRUCTIOMmack an wea 1 -- UNDERGROUND PIPING I ABOVEGR3UND PIPING SYSTEM TYPE ❑1.PRESSURE ❑2.SUCTION [13.GRAVI'T'Y 459. ❑I.PRESSURE ❑2.SUCTION ❑3.GRAVITY 159. CONSTRUCTION/ 1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. MANUFACTURER ❑1.SINGLE WALL '095.O 462 ❑2.mUBLE WAIL 95.UNKNOWN ❑2.DOUBLE WALL ❑99,OTHER MANUFACTURER 461. MANUFACTURER 461. ❑1.RARE STEEL [16.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STBEL ❑7.GALVANIZED STEEL. ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS K95.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑S.FLEXIBLE HOPE) ❑99.OTHER [14.FIBERGLASS [19-FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS Q 9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING 95.UNKNOWN 465. VQ.PEKNG-UEAXDETECPIONlc6mkmi,w 1 irova mwijwdgramsmlrbe.>vtroatedto thrtml: .) . UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467, PRESSURIZED PIPING(Check of that apply): PRESSURIZED PIPING(Check at that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBL.E AND VISUAL ALARMS. -AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST [33. ANNUAL INTEGRITY TEST(0.1 GPH) (:13. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check at that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 136. TRIENNIA.INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELFMONITORING [19+ BIENNIAL INTEGRITY TEST(0.1 GPIU GRAVITY FLOW(Check all that apply): ❑S. DAILY VISUAL MONITORING (39. 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 WITfi AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check oro) ❑a.AUTO POW 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 mac. NO AUTO PUMP SHUT OFF [3c. NO AUTO PUMP SHUT OFF ❑II. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION 11 AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) [112.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) C]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 RESTRICTION DETECTOR (3.0 GPH TEST) WITHOUT FLOW 15.AUTOMATIC LINE LEAK DETECTOR-(3.0 GPH TEST) [116. ANNUAL INTEGRITY TEST In.I GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT.. - DISPENSER CONTAINMENT W. ❑1, FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE C]4. DAILY VISUAL CHECK 469. DATEINSTALLED 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCFI/LBNER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IR,OWNEWOPERATOIL SIGNATURE I cemfy that the information provided here and accurate to the best of my knowledge. SIC TORE 01 DATE: 4" N ERAT (Prior). woe a,V`Q, TITLE OF OWNER/OPERATOR: 472 Pe Nombm(Agency.only) 471. 1 Permit Approved By(Agew,use only) 474. 1 Permit Expiation Date(Ageecy use only) 475. UPCF hwfwrc-b(1/99)-314 http://www.=idms.org Rev.OV16MO