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09/29/2005 10:57 2094683433 EHD PAGE 19 UNIFIED PROGRAM CONSOLIDATED FOR-NI TANKS UNDERGROUND STORAGE TANKS- TANK PAGE 2 Pae of . vl.:PUPnvG-colvsrRucTloNccaa6�ant�r 11 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE PRESSURE ❑2,SUCTION ❑3.GRAVITY 45& L PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ©],SINGLF,WALL ❑3.LINED TRENCH ❑99,OTHER 460. MANUFACTURER ❑1.SINGLE WALL ❑9$.UNKNOWN 462. 2.DQUSLE WALL ❑95,UNKNOWN Q 2.DOUBLE WALL ©99,OTHER MANUFACTURER OL MANUFACTURER 463. ❑ I.BARE STEEL ❑S.FRP COMPATIBLE wn 00°.6 METHANOL ❑I.BARE MEL ❑6.PRP COMPATIBLE w/1 00%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL [1.2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑9$.UNKNOWN ❑S.PLASrrc COMPATIBLE wl CONTENTS ❑8.FLEXIBLE(HDPE) p 99,OTHER $,4.FIBERGLASS ❑S.FLEXIBLE(HOPE) ❑99.OTHER ❑4.FIBERGLASS 0 9.CATHODIC•PROTECTION ❑5,STEEL W/COAT[NG ❑9.CATHODIC PROTECTION 464. ❑S.STEEL W/COATING L3 95,UNKNOWN 465 . ... "'VII.PIPING'LEAK , AE�'ECTION'fc�eckalittwi� v>lnd�cri ianotc6o;nonioori o .gins>nlrtie�tin;haep'iottie•ia41-_ UNDERGROUND PIPING ABOVEGROUND PIPnvG SINGLE WALL PIPING 466. SINGLE WALL PIPING 40,PRESSURIZED MPINC;(Click all 0atapplv): PREUVRIZED PIPING(Chcck all that apply): ❑ L. ELECTRONIC LINE LEAK DETECTOR 3,0 GPH TEST M):tg AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT-OFF FOR LEAD SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. µAUDrgLE AND VISUAL ALARMS. ❑2. MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.3 GPH) []3. ANNUAL INTEGRITY TEST(0.I GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIX14 , INTEGRITY TEST(0.1 GPH) 05. DAILY VISUAL MONITORING OF PIPrNG AND PUMPING SYSTEM SAPS SUCTION SYSTEMS(NO VALVES INBELOW GROUNDPIPING). 06. TRIENNIAL INTEGRITYTEST(O.tGPH) ❑7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW p 7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 Gp4 GRAVITY PLOW(Check all that apply): ❑8. DAILY VISUAL M0NzTORING L19. BIENNIAL IN'T'EGRITY TEST(O.I GPH) SECONDAIR&Y CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check an that apply): 10, CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ta. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check ono) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ,.b-AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b,AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION' ��,// ❑c. NO AUTO PUMP SHUT OFF [3c, NO AUTO PUMP SHUT OFF YA 1. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITFI FLOW SHUT OFFORRESTR1cTrON ❑11-AUTOMATIC LEAK DETECTOR ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 OPH) SUCTION/GRAVITY SYSTEM SUCTIONICItAV1'I'Y SYSTEM ❑33. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Click all that apply) FMERGLNCY GENERATORS ONLY(Check all that apply) [314. CONTINUOUS SUMP SENSOR WI- THOU AUTO PUMP SHUTOFF Q t4.CONTINUOUS SUMP SENSOR w�Z AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15, AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) W�7; o TT FLOW SHUT OFF OR RESTRICTION ❑15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑16, ANNUAL INTEGRITY TEST(0.1 GPH) 1116-ANNUAL INTEGRITY TEST(0,I GPH) [:117. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VIII.DISPENSER.CONTAINMENT DISPENSER CONTAIN ME460. ❑t. FLOAT MECHANISM THAT S1tuTS OFF SHEAR VALVE L]4.4. DA1VISUAL CHECK 469. DATE INSTALLED NT (]2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING C2.3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS [16. NONE IX.OWNER/OPERATOR.STGNATURE I certify that tI1 t Otmatio rovi in is true an urate to the ticst of my knowledge. SIGNATURE grMEW DATE: ` 470. NAME OF OwNER/OPERArgR TITLE OF OWNEWoPERATGR; 472 Permit Number(AEcucy use only) 473. Pcni*Approved By(Agency use only) 474. Penoit Expiration Pak(Ag6,tty ase only) 475. UPCF hwfwre b(I/99)-314 htip://www.unidocLarg Rev.OZ 16100