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tTIFIED PROGRAM CONSOLIDATED FOR TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 W.PIPING CONSTRUCTION ICMck asmetaPpith UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑&5. UNKNOWN MANUFACTURER ❑ 2 DOUBLE WALL ❑95. UNKNOWM ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER 1.BARE STEEL ❑ 8. FRP COMPATIBLE W/1W%METHANOL ❑ 1. BARE STEEL ❑ 5. FRP COMPATIBLE W/100%METHANOL MATERMLSAND ❑ 2 STAINLESS STEEL ❑ T. GALVANIZEDSTEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZEDSTEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE VATH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ e. FLEXIBLE(HOPE) N. OTHER ❑ L FIBERGLASS ❑ S. FLEXIBLE(HDPE) ❑89. OTHER ❑ 4. FIBERGLASS ❑ 9.CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WI COATING 11 95. UNKNOWN VII.PIPING LEAK DETECTION(Chockae IWOA*) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALLPIPING PRESSURIZED PIPING(Check as Mat apply): PRESSURIZED PIPING(Check 09 Mer apply): ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST VATH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST NTH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS 112. MONTHLY0.2GPHTEST 1:1 2. MONTHLY GPM TEST 113.ANNUAL INTEGRITY TEST 10.1 GPM) ❑ 3. ANNUAL INTEGRITY GRITY TEST(0.1 GPM) }��/jy�� ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: No //+"✓'W� CONVENTIONAL SUCTION SYSTEMS(Chack W tat apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPINGSYSTEM♦TRIENNIAL PIPIN INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ B. TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING). ❑ T. SELF MONITORING ❑ T. SELF MONITORING GRAVITY FLOW: GRAVITY FLOW(Check 0 fat appy): ❑ 9. BIENNIAL INTEGRITY TEST 10.1 GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(01 GPM) _ SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Clock as Mat appy): PRESSURIZED PIPING(Cock 89 tat appy): 10. CONTINUOUS WITH 10.CONTINUOUS TURBINE SUMP SENSOR US TURBINE BUMP SENSOR TH AUDIBLE AND VISUAL ALARMS AND WITH AUDIBLE AND VISUAL ALARMS AND(che k one) _ ❑ A AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e. AUTO PUMP SHAT OFF WHEN A LEAK OCCURS ❑ b AUTO PUMP SMUT OFF FOR LEAKS SYSTEM FAILURE AND SYSTEM DISCONNECTION 11p, AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ c NO AUTO PUMP SHUT OFF ❑ C. NO AUTO PUMP SMUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK OETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST 10.1 GPM) SUCTION*RAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check a9 Mat appy) EMERGENCY GENERATORS ONLY(C)mck ad Met appy) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18.ANNUAL INTEGRITY TEST IDA GPM) ❑ 18. ANNUAL INTEGRITY TEST KA GPM) ❑ 1T. DAILYVISUALCHECK ❑ tT. DAILY VISUALCHEOK VM:DISPENSER CONTAINMENT DISPENSERCONTAINMENT. ❑ 1. FLOAT MECHANISM THATSHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INST. PLLE0 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ TRENCH UNER I MONITORING Inl(^.•,L�yy�1►Q• ❑ 3 CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS 8. NONE IX OWNER/OPERATOR SIGNATURE I Panty Mal Me efoonaeon Pmvieae Main H hue we a mte to Ma beet of my knowledge. SIGNKTUREOFOVMER/OPERATOft DATE NAME OF OWNER/OPERATOR(poll) TITLE OF OWNEWOPERATOR PMme Number(Forlocal.omy) Pamlll AMM*Y*e(Fpr up olW Wnral Ezpiraaan OW(FOTbW uas Dray) L3 7-0 CUPAFORM(4199) Fotmotly SVVRCB Form B