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Uh:ED PROGRAM CONSOLIDATED FORD TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION(check all that apply) Page 9 of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ L PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ L PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCnON ❑ 1.SINGLE WALL ❑ 3.LINED TRENCH ❑ 99.OTHER 460 ❑ 1.SINGLE WALL ❑95.UNKNOWN ❑ 2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL El99.OTHER 463 MANUFACTURER 461 MANUFACTURER ❑ L BARE STEEL ❑ 6.FRP COMPATIBLE w/IWA METHANOL ❑ L BARE STEEL ❑ 6.FRP COMPATIBLE w/JO A METHANOL ❑ 2.STAINLESS SITE ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEE 117.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENT'S ❑ 95.UNKNOWN ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER [:IS.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ S.STEEL W/COATING ❑9.CATHODIC PROTECTION 469 VII.PIPING LEAK DETECTION(Check all that appy)(A description of the m snoring program shall be eubmittM to the tical agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that appM'. PRESSURIZED PIPING(Check all that apply) ❑ 1.ELECTRONIC LEVE LEAK DETECTOR 3.0 GPH TEST Tl iTH AUTO PUMP ❑ I.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WT 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 ❑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 ❑ S.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM PIPING 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(Check all Nat apply}. ❑ 8.DAILY VISUAL MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.0 GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check an 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 onn) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ It.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION SYSTEM DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑c. NO AUTO PUMP SHUT OFF ❑ U.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH ❑ 11.AUTOMATIC LEAK DETECTOR FLOW SHUT OFF OR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST A I 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(LTeck all that awry) EMERGENCY GENERATORS ONLY(Check all that ammly) ❑ 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 VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 [:12.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER(OPERATOR SIGNATURE 1 cortify the the mforrrntlon provided hert:in is me and accurate to the bast of ray knawkilp. SIGNATURE OF OWNER/OPERATOR DATE 479 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR al 472 Pemut Nturtber(For heal use only) 473 Pemtit Approved(Far localuse only) 474 Pemvt Expbeiw Date(For oral arc only) 475 EE0000646 12/31/199 UPCF(12/99 revised)