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a -- IED PROGRAM CONSOLIDATED FORIP TANKS ;2 ;UNDERGROUND STORAGE TANKS - TANK PAe of VI.PIPING CONSTRUCTION(Check HI that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 0 I.PRESSURE [12.SUCTION [13.GRAVITY 45rj.PRESSU�RtE 0 2.SUCTION 03.GRAVITY 459CONSTRUCTION/ 01.SINGLE WALL 03.LINED TRENCH 0 99.OTHER 46GLE WALL 095.UNKNOWN 462. MANUFACTURER 02.DOUBLE WALL 0 95.UNKNOWN UBLE WALL 0 99.OTHER MANUFACTURER 461, MANUFACTURER 463. ® I.BARE STEEL 0 6,FRP COMPATIBLE W/100%METHANOL [11.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) [199.OTHER [14.FIBERGLASS [18.FLEXIBLE(HDPE) 0 99.OTHER 0 4.FIBERGLASS 0 9,CATHODIC PROTECTION 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464. 0 5.STEEL W/COATING 0 95.UNKNOWN 465. VIL PIPING LEAK DETECTION(Check ell that a ly)(A description ofthe monitoring program shall be submiued to the keel agency. UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 0 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 01. 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. E12. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) 0 3. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) 0 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): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) 0 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING 09+ BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): 0 8. DAILY VISUAL MONITORING 09+ 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) 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 b. AUTO POW SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b.AUTO DISCONNECTION POWSHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION Dc. NO AUTO PUMP SHUT OFF 0c. NO AUTO PUMP SHUT OFF ❑ 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 GPH) 012. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF 0 14. CCONNTIINUOULE NSS SUMP ASENSORLI HOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW D 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [116+ ANNUAL INTEGRITY TEST(0.1 GPH) Cl 16. ANNUAL INTEGRITY TEST(0.1 GPH) C]17. DAILY VISUAL CHECK 0 17. DAILY VISUAL CHECK VDI,DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. 0 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4. DAILY VISUAL CHECK 469. DATE INSTALLED 012. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 0 5. TRENCH/LINER MONITORING D 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the information pro ' d herein is true and accurate to the best of my knowledge. / 470. SIGNATURE OF OWN R O 472, NAMEOFOW T R(print): 112o TITLE OF OWNER/OPERATOR: Permit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) ;75 UPCF bwfwrc-b(1/99)-3/4 www.unidocs.org Rev.02/16/00