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UNDERGROUND STORAGE TANKS - TANK PAGE 2 q Pae of i -.VI.PIPING:CONSTRUCTION wheckall m. "'GE Or:E UNDERGROUND PIPING I ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑2.SUCTION [13.GRAVIFY 458. 1 ❑1.PRESSURE ❑2.SUCTION [13.GRAVITY 459. CONSTRUCTION/ [11.SINGLE WALL ❑3.LINED TRENCH [199.OTH R 460. I [11.SINGLE WALL [195.UNKNOWN 462. MANUFACTURER 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. 1 MANUFACTURER 463. ❑1.BARE STEEL [16.FRP COMPATIBLE W/1000/.METHANOL (:11.BARE STEEL [16.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS [195.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) [199.OTHER ❑4.FIBERGLASS [18.FLEXIBLE(HDPE) [199.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION W5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. [15.STEEL W/COATING ❑95.UNKNOWN 465, VEL PIPING LEAK DETECTION-(Chea all thm ly)(A deseiipbw ofthe monaonng program shellbe aabmtned a the lmg ag"e.I UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466SINGLE 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 [11. 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 +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST [12. MONTHLY 02 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) [13, ANNUAL INTEGRITY TEST(0.1 GPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all 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): [36. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW ❑7. SELFMONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18+ DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPI) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check a0 that apply): 10. CONTINUOUS TURBINE SUMP SENSOR -WM AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR MM AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Cheek one) a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑L 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 DISCONNECTIONDISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) [112. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [113. 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) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW [115.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [116.ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK [117.DAILY VISUAL CHECK VM.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. []1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE E]4+ DAILY VISUAL CHECK 469. DATE INSTALLED 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/L1NER MONITORING ❑ CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6. NONE DISPENSER+AUDIBLY AND VISUAL ALARMS DL OWNERIOPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF DATE: 470. NAME OFO OTQ; 'n0: � f , TITLE OF OWNER/OPERATOR: 473' Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) n4. Permit Eapimtiov Date(Agency use only) 475. 63