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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPING CONSTRUCTION(Ctlaak aplMtappy)UNDERGROUND PIPING AEOVEGROUND PIPING r ❑ t PRESSURE SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY W ❑ 1. SINGLEWALL ❑ 3, LINEDTRENCH ❑99. OTHER ❑ 1. SINGLEWALL ❑95. UNKNOWN ER ❑ 2 DOUBLEWALL �5UNKNOWN ❑'2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER BARE STEEL ❑ 8. FRPCOMPATIBLEW/100%METHANOL ❑ 1. BARE STEEL ❑ B. FRP COMPATIBLE WI 100%METHANOL D ❑ 2. STAINLESSSTEEL ❑ T. GALV INIZEDSTEEL ❑ 2. STAINLESSSTEEL ❑ T GALVANIZEDSTEEL ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 0. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEKIBLE(HOPE) ❑99. OTHER ❑ 4. FIBERGIASS ❑ S. FLEKIBLE(HDPE) 0. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑ S. CATHODIC PROTECTION ❑ 5. STEEL WI COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION fChack al Mat apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALLPIPING PRESSURIZED PIPING(CMI 0 that apply). PRESSURIZED PIPING(Check aN that apply): ❑ i. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH 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 ❑ 2. MONTHLY 02 GPM TEST ❑ 3 MONTHLYTEGPTTEST ❑ 3. ANNUAL INTEGRITY TEST III I GPM) ❑ S AAILYVINNUAL UAL CHE TEST(0.1 GPH) ❑ 6. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check as fit apply)' ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUALMONITORING OF PIPING AND PUMPING SYSTEM TEST III I GPM) ❑ 6. TRIENNIAL INTEGRITY TEST t0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ T. SELFMONITORING ❑ T. SELFMONITORING GRAVITY FLOWGRAVITY FLOW(Clack as tit appy): ❑ 9 BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 8. DAILYVISUALMONITORING ❑ 9. BIENNIAL INTEGRITY TEST(01 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(CMP*aNNat apply): PRESSURIZED PIPING(CMck 0 Mat apply): 10. CONTINUOUS NOUS TURBINE SUMP SENSOR HATH AUDIBLE AND VISUAL AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(NarA arM) ❑ e. AUTO PUMP SHUT OFF VrHEN A LEAK OCCURS ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ 0. 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 ❑ C. NO AUTO PUMP SMUT OFF ❑ 11 AUTOMATIC LINE LEAK DETECTOR(3 0 GPM TEST)WITH FLOW SMUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST t0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST 10.1 GPM) SUCTIONIGRAVITY SYSTEM'. SUCTIONIGRAVITY SYSTEM', ❑ 13. CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cick MY Hippy) EMERGENCY GENERATORS ONLY(CMA as Mal apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF.AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR AmHOUT AUTO PUMP SHUT OFF.AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC UNE LEAK DETECTOR(10 GPH TEST)AI FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. ANNUALINTEGRITYTEST10.1GPH) ❑ 17. DAILYVISUALCHECK ❑ 1T. DAILY VISUALCHECK VNL DISPENSER CONTAINMENT DISPENSERCONTAINMENT ❑ 1. FLOATMECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DNLYVISUALCHECK DATEINSTALLEO ❑ 2. CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL AIARMS ❑ 5. TRENCH UNERIMONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SMUT OFF FOR DISPENSER.AUDIBLE AND VISUAL ALARMS ❑ 6. NONE IAL OWNER/OPERATOR SIGNATURE I Pinky BMl9»I Iksr uMn payi0e6 herein is Mao aIW a ssaaM b Ma iM M my LnmNa 1p SIGNATURE OF O`MIERIOPERATOR DATE NAME OF OWNER/OPERATOR(aM10 TITLE OF CWMERIOPERATOR PamM Number(Fo ka:ar u»caW Permit Appmke6(F sacN.oMy) PemYl EapkaSm DW(Fwbpl uL axy) CUPAFORM(4/99) ` J Formerly SVVRCB Form B