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FROM J.Schetter PHONE NO. : 5306667692 Mar. 21 2005 04:55PM P6 [UNIFIED PROGRAM CONSOLIDATED FORM TANK UNDERGROUND STORAGE TANKS --TANK PAGE Z pqc_of VI.P1PLtiG ABOVk:GR.OUND PIPIN(i U7,I1117RGR01 IND PIPING 1. 459 SYSTEMTYPE 10 I.PRItSSURE ❑2.SUCTION ❑3,()RAVITY 453 C]1. PRESSURE C]2. SUCTION 05.UNKNOWN AV[TY 462 CONSTRUCnoN ❑),SINGLE WALL [13.LINED TRENCH ❑99.OT14LR 460 ❑1.SINGLE WALL ❑ DOUBLE WALL 99.OTHER ❑2. L'7 MANUFA jUkEg n 2.DOUBLE WALL ❑95.UNKNOWN 463 463 MANUFACTURER MANUFACTURER ©6.FRP COMPATIBLE w/1009.mETIiANOL RE ❑1.BASTEEL [16,FRF COMPATIBLE W/1(0/- MFTFIANOI: D 1.BARE STER• 7.GALVANIZED STEEL (]2.STAINLESS STEEL ❑7.GALVAN1ZtiD STET.. ` [3U��°❑ Q 3. PLASTIC COMPATIBLE' W/CONTENI'S [18.FLEXIBLk•(HDPF) [3 99. OTHER 3.PLASTIC COMPATIBLE W/CONTENTS Q 99. C?ther 4. Ir1BERGl•ASS ❑9.CATHODIC T'R07'ECTION 4.FIBERGLASS ❑8.FLEXIBLE(HDPIi) ❑ ❑95.UNKNOWN 465 05.S•EEL W/COAIING ©9,CATHODIC PROTECTION 464 ❑5. STh8L W/COATING VII.PIPING LEAK DETECTION(Check an that appty)(A CW 'pion of the monitQrin roltrarn almlA O(t `KOittvd UNT)PIPING ') UNDL•RGRO(1ND PIPING, 467 SINGLE WALL PIPING PRESSURIZED SINGLE WALL PRESSUR17F,D PIPING(Chock all that apply): PRESSURIZED P1rING(chtxk au 11W apply) LI 1.ELECTRONIC ETNE LEAK DETECTOR 3.0 GPI I TEST W11 AUTO PUMP SH(TT ❑1. Et.ECTROMC LINELEAK fiAK DETECTOR 3.0 GPH TEST W]TIi AUTO PUMP OFF FOR 1,EAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION 1 .AI.UT Orl' FOR VISUAL AS71 - FAILERE,AND SYSTFM DISCONNEC'1'3ON+ AUDIBLE AND VISI ALARMS. ❑2. MONTHLY 0.2 GPI(TEST ❑2.MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.1GPH) ❑3.ANNUAL INTEGRITY TEST(0-IGPH) [14. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Chink all tlu=apply) ❑5,DAILY VISUAL MONITORING OF PUMPINCT SYSTEM-�TR INIAL PIPING ❑5, DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TIS T(0.1 GPII) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑6. TRIENNIAL INTIiGRITY TEST(0.1 GPH) E3 7.SELF MONITORING SAFE SUCTION SYSTI(MS(NO VALV 1=.S IN BELOW GROUND PIPING)' GRAVITY R,OW C1 7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(check all that apply)! ❑8, DAILY VISUAL MONITORING ❑9. BIENNIAL JNTI&GRITY TEST(0.1 GP14) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING((heck au that apply): PRESSURIZED PIPING(Cheek all that apply) 10. CONTINUOUS TURBINE SUMP SENSOR AUDI TILE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIT UP AND VISUAL ALARMS AND(Check one) ALARMS AND(Check otic) M& AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT•()FF WHEN A LEAK OCCURS ®h. AUTO PUMP SHUT OFF FOR LIEAKS,SY$TF.M PAILURL AND SYSTEM ❑h AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM ITATLURE AND SYSTEM DTSCONNF.('TION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF ❑c NO AUTO PUMP SHUT OFF 10 11, AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHIIT 1I AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12- ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0,1 OR 1) SUCTION/GRAVITY SYSTF.-M SUCTION/GRAVITY SYSTEM i 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [3 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL.ALARMS EMERGENCY GENERATOR$ONLY(Cheek all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITH i T AUTO PUMP 0111JT OFF a ❑14. CONTINUOUS SUMP SENSORI'tW KOUT AUTO PI JMP SI4UT OFF AUDIBLE' AND VISUAL ALARMS AUDIRLF AND VISI)AI.ALARMS ❑15, AUTOMATIC IXI F..LEAK DF.TF.CTOR(3.0 GPH TEST)YAlBOIET FLOW SHUT OFF OR RESTRICTION D 15. AUTOMATIC LINE LEAK DETECTOR(3,0 GPH TEST) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) LI 16.ANNUAL rNTpGRTTY TEST(0.1 CP14) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER LY)NTAINME•NT ❑L FLOAT MECHANISM'I HAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISLIAT_CHFCK DATE INSTALLED 46R ©2.CONTINUOUS DISPENSER PAN SENSOR*AUDIBLE AND VISUAL ALARMS ❑S.TRP.NCH T.TNFR/MONITORING M 3.CONTINUOUS DISPENSER PAN SENSOR=AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑G.NONE 409 IX.OWNF:R/OPERATOR SIGNATURF. I certify that the infpmation provided harein is true and accurate to the best of my knowledf;.e. ST(1NATI.IRF. . (.')17 A (lR I DATE 490 03/2112005 NAME OF O R/OPRATO (prl TITLE OF OWNER/OPERATOR 47-' John Sc ett r Environmental Compliance S ecilist berm c xum (F 1 c 1 oao oaiy) 47.1 Pe ;t Arj-,l(Fr twat„ae nary) Pnmit F.:p rarinn Elate(Fne loco] n„iy) 47S