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.IFIED PROGRAM CONSOLIDATED FOZi��/ TANK: TA0133003 PR#: PRO231330 FAC#: FA0003964 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(CMkaB mat wly) Page 3 oft UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑ L PRESSURE ❑2.SUCTION ❑3.GRAVITY 459 CONSTRUCTION ❑�_�1 SINGLE WALL E13.LINED TRENCH ❑99.OTHER 460 E] 1.SINGLE WALL El 95.UNKNOWN 462 [k�2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL [199.OTHER MANUFACTURER - 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE al 100%METHANOL ❑ I.BARE STEEL ❑6.FRP COMPATIBLE el 1001i METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS [I 9S.UNKNOWN El PLASTIC COMPATIBLE W/CONTENTS El 95.UNKNOWN I•-d-J4.FIBERGLASS ❑ B.FLEXIBLE(HDPE) ❑ 99.OTNER [14.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ 99.OTHER [15.STEEL W/COATNG ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATNG ❑9.CATHODIC PROTECTION 469 VII.PIPING LEAK DETECTION(C 0 ma Wly)(A demipion of dw momiumine pmgam shall be eubmmedwthe lwl aaenty) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND VISUALALARMS. VISUAL ALARMS. ❑2.MONTHLY 01 GPH TEST ❑ ❑ 2.MONTHLY 0.2 GPH TEST E] 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+TRIENNIFAL PIPING ❑5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRrrY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): El 7.SELF MONITORING GRAVITY FLOW ❑ 7.SELF MONITORING ❑'9.BIENNIAL INTEGRITY TEST(0.0 GPH GRAVITY FLOW(Check a0 that apply): ❑8.DAILY VISUAL MONITORING ❑9.BIENNIAL INTEGRITY TEST B.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(CMkoa) ALARMS AND(Chuk ore) ❑ 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 Zc.SCONNFCIION DISCONNECTION NOAUTO PUMP SHUT OFF ❑ C.NO AUTO PUMP SHUT OFF 19/11.'FSTRICTION CLINE LEAK DETECTOR(3.0 GPH TEST)'(FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR 212.ANNUAL INTEGRITY TEST(0.1 GPM ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPI) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY((3ak.11 Wt appy) EMERGENCY GENERATORS ONLY(Click m wt apply) ❑ 14.CONTNUOUS SUMP SENSOR WITFIOUT AUTO PUMP SHUT OFF e ❑ 14.CONTINUOUS SUMP SENSOR WITH OU7 AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ IS.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW El 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION - SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.I GPH) ❑ i7.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DATETENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE El4.DAILY VISUAL CHECK INSTLLED 469 ❑2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ TRENCH LINER/MONITORING E]3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER/OPERATOR SIGNATURE l aerllyaw Melo IS we aM aeaeaeeb lh6w ofmyhwkdge SIGNATURE OF OWNER/OPERATOR DATE 479 NAME OF OWNER/OPERATOR(print) TITLE OF OWNERIOPERATOR 471 OE Paait Nemba(Falooluaony) 473 Permit AMmul(F9rbnlumorly) 474 Pcmw Expimim Dnc(For laol we only) 475 PT0006610 EE0000817 1/1/1993 UPCF(12/99 revised)