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NIFIED PROGRAM CONSOLIDATED FO. TANK: TA01604M v \� PR#: PR023IW4 FAC#: FA0000650 UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION(cleat 0 Aa,appy) Paha34n UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ I.PRESSURE ❑ 2.SUCTION ®3.GRAVITY 458 ❑ 1.PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 459 O0HURLX7KN ❑I.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 El 1.SINGLE WALL ❑95.UNKNOWN m2 M11DOUSLEWALL ❑95.UNKNOWN El 2.DOUBLE WALL 99.OTHER MANUFACTURER A 0 SMITH 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑6.PEP COMPATIBLE w l00K METHANOL ❑ 1.BARE STEEL [16.FRP COMPATIBLE.N 190%METIiANOL ❑ 2.STAINLESS STEEL [17.GALVANIZED STEEL [12.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑95.UNKNOWN ❑PLASTIC COMPATIBLE W/CONTENTS ❑95.UNKNOWN M 4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING [19.CATHODIC PROTECTION �5 VII.PIPING LEAK DETECTION(Cl Al Ma apply)(A6 pawotos nmolmalaa ptoeamsWlW s,nn muab atar.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 05 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check a8 that apply): ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST W TTH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH 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 0.2 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) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ S.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 ❑ 7.SELF MONITORING GRAVITY FLOW ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Cheek all that apply): ❑8.DAILY VISUAL MONITORING [-19.BIENNIAL INTEGRITY TEST(0.1)GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check W that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Lhharc) ALARMS AND(Chat.) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑h.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑I.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 LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 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(�a tha appy) EMERGENCY GENERATORS ONLY(C all appy) ❑ 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 VIU.DISPENSER CONTAINMENT DISPENSER CONTAINMENT E] 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATEINSTALLED MS 2 CONTINUOUS 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 469 M OWNER/OPERATOR SIGNATURE I cony tlm Mn inTw wpmri Man iso W a a+ractp usual army Y Icdgc, SIGNATURE OF OW NEWOPERATOR DATE 470 NAME OF OWNEIVOPERATOR(Print) TITLE OF OWNER/OPERATOR JANET HEIIIEL 071 RISK MANAGER 4 72 Pa IN=bc(Fvl-fm o*) 473 P-AAWp mi(Falca oaty) 474 P-tP PimOntc(Fa loaf me m Y) 475 PT0000655 EE0003804 12/31/2000 12:00:00AM UPCF(12/99 revised)