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U''ED PROGRAM CONSOLIDATED FORM TANK: PR N: UNDERGROUND STORAGE TANKS - TANK PAGE FAC M: VI.PIPING CONSTRUCTION(Chat aE Ilubppy) UNDERGROUND PIPING r.etl orJ ABOVEGROUND PIPING SYSTEM TYPE ❑ I-PRESSURE ❑ 2.SUCTION 3.GRAVITY ase ❑ NPRESSURE ❑ 2.SUCTION ❑ I.GRAVITY 459 coN5TR1KTlory �}L SINGLE WALL ❑J.LINED TRENCH ❑99.OTHER a6o ❑2.DOUBLE WALL ❑95.UNKNOWN ❑ LSINGLE WALL 095.UNKNOWN 462 MANUFACTURER 461 ❑2.DOUBLE WALL ❑ 99.OTHER a.� MANUFACTURER 463 1O1.BARE STEEL ❑6.FRP COMPATIBLE w/1(0ffi METHANOL ❑ 1.BARE STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 6.FRP COMPATIBLE wi 1002 METHANOL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HOPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 95.UNKNOWN ❑ 5.STEEL W/COATING ❑ 9,CATHODIC PROTECTION ❑ 8.FLEXIBLE(HDPE) ❑99,OTHER 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION VII.PIPING LEAK DETECTION(Clerk aE I 1 "e Ppy)(Ade plo eflhmmita p mah llb nbmhldlPth bml•ery) UNDERGROUND PIPING SINGLE WALL PIPING ABOVEGROUND PIPING PRESSURIZED PIPING(Check all that o I 466 SINGLE WALL PIPING apply): PRESSURIZED PIPING(Check all that a I 467 ❑FOR L 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 VISUAL FAILURE, SYSTEM DISCONNECTION' AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION-AUDIBLE AND VISUAL ALARMS. ❑2.MONTHLY 0.2 GPH TEST VISUAL ALARMS. ❑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 SUCr10N SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING E]5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6.TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): GRAVITY FLOW ❑ 7.SELF MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Checkall that apply): ❑ 8.DAILY VISUAL MONITORING ❑ SECONDARILY CONTAINED PIPING 9.BIENNIAL INTEGRITY TEST(0,1)GPH PRESSURIZED PIPING(Check all that apply): SECONDARILY CONTAINED PIPING10. PRESSURIZED PIPING(Check all that apply): ARABINLARMS AND(CTW mc) CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Ch kale) ❑ 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 DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑C.NO AUTO PUMP SHUT OFF ❑ 11.AUTOMATIC LME 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(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ U.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chat all wt appy) EMERGENCY GENERATORS ONLY(Chat all"appy) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WrrHO AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMSG AUTO PUMP SHUT OFF• ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW El15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SRUT 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 ❑ 1,FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑ 4.DAILY VISUAL CHECK 4ox ❑ 2.CON'I INUVUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ S.TRENCH LINER MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 40 IX.OWNEWUPERATOR SIGNATURE IThry lhal He mf ti6apmvkkd "nh hue and omit la the bel 6faY knowledge. SIGN ATURE0 OWN PM PtAT90 DATE I Z h? to 479 NAME TOWN BATOR(FP^^ggt) TITLE OF OWNEWOPERATOR a L`Pi /91 r/( G� Pr<s,Qe�, 472 PamitNanba(Fm tool ufeaJY) 473 Permit Ap ad(PalaalmcmlY) 474 Pemil Ea Phalion M.(Fm tical ive mlY) 475 UPCF(12/99 revised)