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b 1 16 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 Pae of Vl.PIPING CONSTRUCTION(t &.ntlw e ) UNDERGROUND PIPING I ABOVEGROUND PIPING SYSTEM TYPE O L PRESSURE 0 2.SUCTION O 3.GRAVITY 459. O 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 459. CONSTRUCTION/ 0 1.SINGLE WALL [13.LINED TRENCH 0 99.OTHER Mo. 0 1.SINGLE WALL E9 95.UNKNOWN 462. MANUFACTURER 0 2 DOUBLE WALL 0 95.UNKNOWN 0 2.DOUBLE WALL 0 99.OTHER MANUFACTURER 461. MANUFACTURER 463. 0 1.BARE STEEL 0 6.FRP COMPATIBLE W/100°A METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W IN%METHANOL [12.STAINLESS STEEL O 7.GALVANIZED STEEL O 2.STAINLESS STEEL O 7.GALVANIZED STEEL O 3.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 0 911-OTHER O 4.FIBERGLASS O S.FLEXIBLE(HDPE) O 99.OTHER O 4.FIBERGLASS [19.CATHODIC PROTECTION ❑5.STEEL.W/COATING 0 9.CATHODIC PROTECTION 464. 0 5.STEEL W/COATING ®95.UNKNOWN 463. VII.PIPING LEAK DETECTION tch, .0 tiro• Ad.uriotim orae m..itain mall h mbmiWd O D.local UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check.11 that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST M TH AUTO PUMP SH[R-0FF 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 02. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(0.1 GPH) O 3. ANNUAL INTEGRITY TEST(0.1 GPH) O 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) O 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING [35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPF) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): 06. TRIENNIAL INTEGRITY TEST(0.1 GPH) 0 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELFMONITORING 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that appy): O S. DAILY VISUAL MONITORING 09. BIENNIAL INTEGRITY TEST(0.I GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check ell that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WIT AUDIBLE AND VISUAL ALARMS AND(Check.) ALARMS AND(Check once) 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUTOFF Oc. NO AUTO PUMP SHUT OFF 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 0 11.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION 0 12. ANNUAL INTEGRITY TEST(0.1 GPI) 0 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCIION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS O 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF 0 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW O 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION 016. ANNUAL INTEGRITY TEST(0.1 OPt) 0 16.ANNUAL INTEGRITY TEST(0.I GPH) 017. DAILY VISUAL CHECK O 17.DAILY VISUAL CHECK VIIL DISPENSER CONTAINMENT DISPENSER CONTAINMENT 466. 0 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04. DAILY VISUAL CHECK 469. DATE INSTALLED 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCH/LINER MONITORING 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ®6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNERIOPERATOR SIGNATURE I certi a MfQrnrati2Lmvidcd h rein is true and accurate to the best of my knowledge. SI FOWNEr DATE:25 MAY 2006 aa. N OFOWNER/OPERATOR(print): CHRISTOPHERMILLER TITLE OFowNER%oPERAToR: AGENT FOR OWNER °" Pemut Number(Agcy we only) 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 435. UPCF hwfwre-b(1/99)-314 http://www.unidocs.org Rev.02/16/00