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IFIED PROGRAM CONSOLIDATED FOR#A111P AI 40.21 TANK: TA0505844 `[ PRO: PR0231310 UNDERGROUND STORAGE TANKS - TANK PAGE 2 FAC k: FA0003%4 VI.PIPING CONSTRUCTION(caek.n the,appy) Pers ars LIN)ERGRO PING ABOVEGROUND PIPEVG 7CONSTRUCTION TEM TYPE ❑ i.PRESSURE 2.SUCTION ❑I.GRAVITY 458 ❑ L PRESSURE ❑2.SUCTION ❑I.GRAVITY ass ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ W.OTHER 469 ❑ I.SINGLE WALL ❑ 95.UNKNOWN 462 ❑2.DOUBLEWALL ❑95.UNKNOWN 02.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 465 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE.,laa%h1ETHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE W l00%METNANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL [12.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS [195.UNKNOWN ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ ".OTHER ❑4.FIBERGLASS EIS.FLEXIBLE(HDPE) ❑ 99.OTHER [15.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Cleet.n tat aptly)(A doc.iptlanofthe mpulorineprniaathan be eubmmWbthe laces agrnryJ UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SAIGLE WALL PIPING 467 P ZED PIPING(Check .R' ll that apFlY): PRESSURIZED PIPING(Check all that apply): I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TESTS AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHAT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑2.MONTHLY 02 GPH TEST ❑2.MONTHLY 0.2 GPH TEST ❑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) El 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+7RKPINIEAL PIPING ❑5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑7.SELF MONITORING GRAVITY FLOW E] 7.SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): [18.DAILY VISUAL MONITORING ❑ 9.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 WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMSAND(Ckerke..) ALARMS AND(C mm) ❑a.AU70 PUMP SHUT OFF W HEN 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 ❑c.NO AUTO PUMP SHUT OFF ❑C.NO AUTO PUMP SHUT OFF 1.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) ❑ 12.ANNUAL INTEGRITY TEST(O.IGPH) 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(Clack an tat apply) EMERGENCY GENERATORS ONLY(C kall that apply) ❑ 14.CONTINUOUS SUMP SENSOR WUHOIIT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.o GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.I GPI) ❑ 16.ANNUAL INTEGRITY TEST(0.I GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VDI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATEINSTALLED 469 El 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS A 469 IX.OWNER/OPERATOR SIGNATURE Ia.6ly tatthmfotwtimptmikdhvem a vucane.¢u..ftb aaa,kanai 1, SIGNATURE OF OWNEWOPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR cel 472 PmtYt Nionbcr(Forkcelmonly) 473 Permit Apprnned(Forkceluconly) 474 Pmnit Expiration D.(I.kcal.only) 475 PT0006610 EE0000817 1/1/1993 UPCF(12/99 revised)