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UNIFIED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Pae of VI.PIPING CONSTRUCTION(check m tw I) UNDERGROUND PIPING I ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE ❑2.SUCTION 953.GRAVITY 458. 1 ❑I.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ El ❑1.SINGLE WALL 3.LINED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL [I95.UINKNOWN / 462. MANUFACTURER N 2.DOABLE WALL ❑95.UNKNOWN F/LL LJN-E ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER "I. I MANUFACTURER 43. ❑1.BARE STEEL ❑6.PEP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE WY 100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑S.FLEXIBLE(HDPE) ❑99.OTHER FR4.FIBERGLASS ❑S.FLEXIBLE(HDPE) [199.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VII.PIPING LEAK DETECTION(Check a0 that I)(A desc'tion ortne nanciering pmgama ii he suhmkted w the Iota a .) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466, SINGLE 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 ❑1. 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 ❑1 MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) [33. 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 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑S. 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(Check one) ALARMS AND(Check one) ❑L AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO PUMP S14UT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION [3c. NO AUTO PUMP SHUT OFF Qe. 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) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SgImeMN/GRAVITY SYSTEM F /(._L.- SUCTION/GRAVITY SYSTEM C3 13. CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS [I L).CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑I4. CONTINUOUS SUMP SENSOR WITH 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) SHUT OFF OR RESTRICTION [316. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. DAILY VISUAL CHECK 469. DATE INSTALLED (32. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE I certify that the information provided heroin is true and accurate to the best of my knowledge. S19NATURE OF OWE C/E bP T";OR , / DATE: ✓ �/O �3 470. N OEOFO�ER/6PER+lT6R(ptin �APjerT TITLE OFR/SW�OPBRttmi9,(t:" �o Permit Number(Agency useonly) 473. 1 Penni)Approved By(Agency use only) 474. 1 Pennit Eipuation Dam(Agency use only) 415. UPCF hwfwrc-b(1/99)-3/4 http://www.unidocs.org Rev.02/16/00