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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION ICMck"6Mt,ppq UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ m 1. SINGLE WALL ❑ 3. LINED TRENCH ❑IN OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑W. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL TT❑� 6, FRP COMPATIBLE W/100%METHANOL 131. BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL MATERIALS AND 112. STAINLESS STEEL t9 T.GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZEDSTEEL CORROSION �[j PROTECTION 133. PLASTIC COMPATIBLE WITH CONTENTS LST9S. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 6. FLEXIBLE(HOPE) 099. OTHER ❑ 4. FIBERGLASS ❑ S. FLEXIBLE(HDPE) 13 Bo OTHER. ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5 STEEL W/COATING ❑ 9. CATHOMCPROTECTION ❑ S. STEEL W/COATING 1395. UNKNOWN NI.PIPING LEAK DETECTION(Chock Y MN appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(CMFk"Mat app M: PRESSURIZED PIPING(CMck aN Mat apply): ❑ 1_ELECTRONIC LINE LEAXDETECTOR LGPH TEST kWTH AUTO.PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DSRCTOR 34Y.-H TEST WITH AUTOPLM-SHUT OFFF ILE!'. - LEAK.SYSTEM FAILURE,AND SYSTEM DISCONNEOTION•AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY 0.2 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST 10.1 GPM) ❑ 3. ANNUAL INTEGRITY TEST(01 GRH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS. CONVENTIONAL SUCTION SYSTEMS(Ckeck"Met apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(01 GPM) ❑ 6 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 SELFMONITORING ❑ T. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Chock a9M at apply): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ B. DAILY VISUAL MONITORING ❑ 9 BIENNIAL INTEGRITY TEST(0 1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chock ab M,(appy): PRESSURIZED PIPING(Check a9 that appy)' 10 CONTINUOUS TURBINE SUMP SENSOR HATHAUDIBLE AND VISUAL ALARMS AND (Cnepk ane) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(tlleck one) ❑ A AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ 5 AUTO SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ 6 AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ e. NO AUTO PUMP SHUT OFF ❑ F. NO AUTO PUMP SHUT OFF ❑ 11 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SMUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION,GIMVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ 19. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chock a9 that appy) EMERGENCY GENERATORS ONLY(Chock a9 MN appy) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND ❑ 14. CONTINUOUSSUMPSENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL VISOALALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WTHOUT FLOW SHUT OFF OR ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ Ia.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILYVISUALCHECK ❑ 17. DAILY VISUAL CHECK WL DISPENSER CONTAINMENT DISPENSERCONTAINMENT ❑ i. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILYVISUALCHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS �❑3r'I S. TRENCHUNER I MONITORING t1" ❑ 3. CONTINUOUSMSPENSER PAN SENSOR WIN AUTO SMUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS a. NONE UL OWNER/OPERATOR SIGNATURE I cartfy IMI Ma k aMat.p-vkaU hemn%s a wk ac-xa est of MY paAa9ga. SIGNATUREOFOWNERIOPERATO r Q DATE Joe manhi 6/5/00 IyoCF1 OVM-ER10pEp.yTOR/p TITLEOFOWNER/OPERATOR Owner PaIrNl NanSar(farKKVus olak) PartMAppmveB(Fxbulum eMkl Pamil EvpkaSm Ow(ForlMlvas aHyl CUPAFORM(4199) ForITIBIty SV1RC8 Form B ��