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✓IFIED PROGRAM CONSOLIDATED FORN._ ( `I, /�03 TANK: TA0505844 �T� PR#: PRO231330 UNDERGROUND STORAGE TANKS - TANK PAGE 2 FAC#: FA0003964 VI.PIPING CONSTRUCTION(c6w1aR 16.1 appy) P"c 5 ors UNDERGRO DPIPING ABOVEGROUND PING SYSTEM TYPE ❑ I.PRESSURE Ed2.SUCTION [13.GRAVITY 459 ❑ 1.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99,OTHER 460 ❑ I.SINGLE WALL ❑95.UNKNOWN 462 ❑2.DOUBLE WALL [195.UNKNOWN El 2.DOUBLE WALL ❑ 99.OTHER MANUFACTURER461 MANUFACTURER 463 ❑ 1.BARE STEEL [16.FRP COMPATIBLE w/Iaa%MEnmNOC ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE w/lao.METHANOL ❑ 2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑ 99.OTHER [:14.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ ".OTHER ❑ S.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 El5.STEEL W/COATING E] A CATHODIC PROTECTION 6 VII.PIPING LEAK DETECTION(C kowualyy)A6vazp,.arlhe eaoilolioa Pla®ata s6,p 6ea,bv,;tleato l6e to y.¢ewy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING esb SINGLE WALL PIPING '& I ZED PIPING(Check all But apply): PRESSURIZED PIPING(Check all that apply): ,] 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TESTWITH AUTO PUMP SHUT 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 ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 2.MONTHLY 0.2 GPH TEST ❑ 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 I TRIENNWAL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) E] 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPNG): SAFE SUCTION SYMMS(NO VALUES IN BELOW GROUNDPIPNG): [17.SELF MONITORING GRAVITY FLOW [:] 7.SELF MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ 8.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 ALARMS AND(Chok arc) ALARMS AND(C we) ❑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 DISCONNEC 70N DISCONNECTION ❑C.NO AUTO PUMP SHUT OFF ❑ c.NO AUTO PUMP SHUT OFF eel I-A AUTOMATIC LINE LEAK DETECFOR(3.0 GPH TEST)WITH FLOW SHUT OFF ORREST ❑ Il AUTOMATIC LEAK DETECTOR ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPIs) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) 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(Cherk an Oat appy) EMERGENCY GENERATORS ONLY(Ch kau eta,q,Py) ❑ 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 LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 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(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ ( FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 09 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 DL OWNER/OPERATOR SIGNATURE I eatiy Wt the inf tion Ponded Memm hueavd a eW to the bot o(Iay knmiedc SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR(Print) TITLE OF OWNER/OPERATOR 471 472 Pcmit Nu MerfFoelool--ly) 473 Pomil Appm (Fmbolaeeo*) 474 P=il I!Vimwa Oate(Fm bol we a y) 475 PT0006610 EE0000817 1/1/1993 UPCF(12/99 revised)