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T Lvt .n PROGRAM-CtTNMT.TIIATF.TI F(1R <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 2 pa e of <br /> VI.PIPING CONSTRUCTION(Check all the tr) ABOVEGROUND PIPING <br /> UNDERGROUND PIPING 459 1 PRESSURE 0 2,SUCTION ❑3.GRAVITY ass. <br /> SYSTEM TYPE L PRESSURE 0 2.SUCTION 0 3.GRAVITY 462. <br /> CONSTRUCTION/ 0',SINGLE W ALL ❑3.LINED TRENCH ❑99.OT}iER �' 0 2 �� WALL <br /> 0 99.OTHER <br /> MANUFACTURER 2.DOUBLE WALL 0 95.UNKNOWN ass. <br /> 461. MANUFACNRER <br /> MANUFACTURER 0 6.FRP COMPATIBLE W/100%METHANOL <br /> ARE STEEL <br /> 0 1.BARE STEEL ❑6.FRP COMPATIBLE W/100°/.METHANOL 0 2.STAINESS STEEL 0 7.GALVANIZED STEEL <br /> 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 0 PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNIOOWN ❑3.PLASTIC COMPATIBLE WI CONTENTS 0❑ PROTECTION 9.FLEXIBLE ❑99.OTHER <br /> 3 0 4.FIBERGLASS 9.CATHODIC PROTECTION <br /> �4.FIBERGLASS S.FLEXIBLE(HDPE) 0 99.OTHER 0 095. <br /> ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION <br /> a6i. 0 5.STEEL W/COATING <br /> VII.PIPING LEAKDETEC'FIONtneck as d,m IY)(A des imddemoo'vc,vi �QVbEGROUN PING <br /> UNDERGROUND PIPING 46z <br /> ash. SIN <br /> GL WALL PIPING <br /> SIN LE WALL PIPING pg URIZED PIPING(Check all that apply): <br /> P SURIZED PIPING(Check all that apply): .0 GPM TEST DETECTOR 3 <br /> ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST N'lTH ALTO PUMP AUTO PUMP <br /> 1' ELECTRONIC FOR LEAKLEAK <br /> SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCOSNECTION +AUDIBLE AND VISUAL ALARMS. <br /> +AUDIBLE AND VISUAL ALARMS. GONT'HLY 0.2 GPH TEST <br /> MONTHLY 0.2 GPM TEST UAL INTEGRITY TEST(0.1 GPH) <br /> ANNUAL INTEGRITY TEST(0.1 GPH) 4, DAILY VISUAL CHECK <br /> CON ENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> CONVENTIONALDAILY <br /> VIS AL MON TORINGSYSTEMS <br /> []5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING <br /> 5. DAILY VISUAL MONITORING OF PING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> 6 TRIENNIAL INTEGRITY TEST(0.1 P <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): O FE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> 0 7. SELF MONITORING 0 7, SELF MONITORING <br /> GRAVITY FLOW GRAVITY FLOW(Check all that apply): <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPH) E38. DAILY VISUAL MONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0,I GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH ALIBLE ANTS VISUAL 10. COMRMOOUSS(TURBINE)SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> PRESSURIZED PIPING(Check all that apply): <br /> Check one <br /> ALARMS AND(Check one) 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS PAUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AVT)SYSTEM DISCONNECTION <br /> DISCONNECTION Oc. NO AUTO PUMP SHUT OFF <br /> JGc. NO AUTO PUMP SHUT OFF <br /> 21k AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT ll, MATIC LEAK DETECTOR <br /> OFF OR RESTRICTION 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> t2. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM - <br /> SUCTIONlGRAVITY SYSTEM 13, CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> 0 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALAR.VIS [113. <br /> EMERGENCY GENERATORS ONLY(Check all that apply) <br /> EMERGENCY GENERATORS ONLY(Check all that apply) 14.CONTINUOUS SUMP SENSOR WITHOUT F AUTO PUMP SHUT OFF <br /> 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF 0 AUDIBLE AND VISUAL ALARMS <br /> AUDIBLE AND VISUAL ALARMS FLOW <br /> 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPM TEST) WITHOUT 015.AUTOMATIC 1.64E LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION ,6 ANNUAL INTEGRITY TEST(0.1 GPM) <br /> ❑ b. ANNUAL INTEGRITY TEST(0.1 GPH) V 17. DAILY VISUAL CHECK <br /> W17. DAILY VISUAL CHECK <br /> VDL DISPENSER CONTAINMENT DAILY VISUAL CHECK 469. <br /> DISPENSER CONTAINMENT 469. • 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE <br /> DATE INSTALLED 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCH/LINER MONITORING <br /> [33. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 06. NONE <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX. VNEWOPERATOR SIGNATURE <br /> 1 certify that the information provided herein's true and accdrhte t the best of my knowledge. / © 470. <br /> SIGNATURE OF OWNER/OPERATOR ,q DATE: <br /> J 0 d]2. <br /> NAME OF OWNER/OPERATOR(print): <br /> 473. Perntit Approved By(Agency use only) 4A. Permit Expiration Date(Agency use only) <br /> 415 <br /> Permit Number(Agency use only) <br /> Rev.02/16/00 <br /> UPCF hwtwrc-b(1/99)-3/4 <br /> http://www.unidocs.org <br />