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I UNIFIED PROGRAM CONSOLIDATED am � I TANKS I UNDERGROUND STORAGE TANKS -TANK PAGE 2 � VI.PIPING CONSTRUCTION(Check ar that adpty) UNDERGROUND PIPING .BOVEGRCUNO PIPING SYSTEM TYPE C PRESSURE :. SUCTION ❑ 3. GRAVITY 1❑ 34 '""I ESSURE 2. S ICT CN L73. GRAVITY CONSTRUCTION! ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLZ WALL ::95. UNKNOWN MANUFACTURER 2. DOUBLE`NALL ❑95. UNKNOWN ❑ 2, DOUBLE'NALL ❑99. OTHER MANUFACTURER .1U1 9, Sn cx MANUFACTURER i ❑ 1,3ARE STEEL ❑ 5. FRP COMPATIBLE`N1 100%METHANOL ❑ 1. BARE STEEL ❑ 3. PRP COMPATIBLE'AM!00%METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ 7. GALVANIZED STEEL C: Z STAINLESS STEEL V T. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE 1MTH CONTENTS ❑95. UNKNOWN ❑ 3. 'LASTIC COMPATIBLE wTH CONTENTS ❑ 9. •z EX;BLE(HOPM ©99. OTHER ❑ 4. FIBERGLASS 3 :7EXIBLEiMOPEI ❑99.OTHER Q a, =1BERGUSS ❑ 9. CArHOOICPROTEC^ON ❑ 5. STEEL W)COATING ❑ 9. sATMODIC PROTECTION ❑ 5. STEEL•Nt COATING 1:195. UNKNOWN VII_PIPING LEAK DETECTION(Chock ad thu apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING I PRESSURIZED PIPING{Check an that apply).. PRESSURIZED PIPING(Choc*alt out appal: I I. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST 1MTH AUTO PUMP SMUT OFF FOR LEAK, I C1 +. =LECTRONTG UNE LEAK DETECTOR 3.D GPH 1•EST'MTIi AUTO PUMP SHUT OFF FOR ❑ _ LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION-AUDIBLE AND VISUAL SYSTEM FAILURQ AND SYSTEM DISCONNECTION-AUDIBLE AND VISUALALARMS ALARMS ❑ 2 ,MONTHLY 0.2 GPH TEST ❑ MONTHLY 0.2 GPH TEST ❑ ;, ANNUALlNTEC.R3TY TEST(0,1 GPH) ❑ 3. ANNUAL INTEGRITY TEST(a.1 GPM) ❑ a, DAILY VISUAL CHECK CONVENTIONAL SUCTICN SYSTEMS: CONVENTIONAL SUCTICN SYSTEMS(Chao*aY that BOPW: ❑ 5. DAILY VISUAL.MCNITCRING OF PUMPING SYS'oM-TRIENNIAL+'tPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM reST(0.1 GPH) ❑ S. 'BIENNIAL INTEGRITY TEST 10.1 GPH) SAFE aUCTICN SYSTEMS(NO VALVES IN BELOW GROUND PIPING); SAFE_STICTION SYSTEMS;NO VALVES W BELOW GROUND PIPING): ❑ SELF MONITORING I c 7. SELF MONtTOANVG GRAVITY FLOW: I GRAVITY PLOW(C.hea(as Met apply): ❑ 9. 91ENNIAL INTEGRITY TEST(0.1 GPM IQ D. GAILY'ASUAL MONITORING Q 3. 31ENNLALtNTEGRITY'ESTFC.1GPHI SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING fCheck ad that apa)yl: I PRESSURIZED PIPING(Chem all that aopry)- •a. CONTINUOUS'uRBINE SUMP SENSOR WITM AUDIBLE AND VISUAL ALARMS AND :q COµ7tµi10U5 URBINE SUMP SENSGR WITH AUDIBLE AND VISUAL ALARMS AND(Wack one) ChwA one) ❑ a. AUTO PUMP SHUT OFF WHEN A IiZAK OCCURS ❑ a, AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM ❑ 0. AUTO PUMP SHUT OFF POR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ a. NO AUTO PUMP SHUT OFF C c ,140 AUTO PUMP SHUT OFF ❑ TI, AUTOMATIC LINE LEAK DETECM. R 13.0 GPM TEST)'MTH FLOW SHUT OFF OR ❑ TI. AUTCMATIC LEAK DET-CTCR RESTRICTION ❑ T2. ANNUAL INTEGRITY EST(0,1 GPHI Q TZ, ANNUAL:NTrcGAITY'EEST(O.I GPHI SVC-.ICN/GRAVITY SYSTEM: SUC:IONIGRAVITY SYSTEM Q T3. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE.AND VISUAL ALARMS EMERGENCY GENERATORS ONLY{Chm*aM tnat apply) EMERGENCY GENPIIATORS ONLY(Cheat ae Mat apply" 14, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+.AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3,0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR 13.0 GPM TESTI RESTRICTION ❑ 1fi. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPHI ❑ '7 DAILY VISUAL CHECK 10 17 DAILY VISUAL CHECK VIB.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE Q 4, DAILY VISUAL CHECK DATE INSTALLED Q 2. CONTINUOUS DISPENSER PAN SENSOR*AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH UNER t MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUAL ALARMS ❑ 3. NONE IX.OWNEWOPERATOR SIGNATURE centy that the intomaaon oroulded ne~i is;tue afa accurate to the oest of my Krowledge. SIGNATURE OF•OWNERlOPERATCR oATe i NAME OF OWNEWOPERATOR rpnnrl -- - -ITLE OF OWNEWOPERATOR 4 P+1 11 NUmoer fFor rOM use only) Penmt Approved(Far local use only) I} ;,m,I Ecpaanon Date(Pomo)use only) CUPAFORM(4199) • 0 Formerly SWRCS Form B