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TTNTFIFD PR(i(:R AM('fTNR[li.TP 4TRiT FlTI2 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pae of <br /> VI.PIPING CONSTRUCTION(check.0 tnaz ) ABOVEGROUND PIPING <br /> UNDERGROUND PIPING459. <br /> SYSTEM TYPE 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. LPRFS4URE ❑2.SUCIHON ❑3.GRAVITY 46z. <br /> 1.,6�INGLE W ALL [13.LINED TRENCH ❑99-OTHER 460. ❑1. LE WALL ❑95.UNKNOWN <br /> CONSTRUCTION/ LL-i/ �Wl ❑99.OTHER <br /> MANUFACTURER 2 DOUBLE WALL ❑95.UNNI')O 463. <br /> 461. MANUFACTl1RER <br /> MANUFACTURER ❑6.FRP COMPATIBLE W/I 00%METHANOL <br /> ❑1 BARE STEEL ❑6.FRP COMPATIBLE W/100°/.METWANOL O 2.ST INLESS SEL ❑7.GALVANIZED STEEL <br /> ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL <br /> 7/PLASTIC COMPATIBLE WITH CONTENTS 0 95'UNKNOWN <br /> [13. <br /> 3. ASTIC COMPATIBLE <br /> FIBERGLASS PATBLE W/CONTENTS O 9 CATHODIC FLEXIBLE PRO PROTECTION <br /> ❑99 OTHER <br /> 1!1'44.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER [1 [195.UNKNOWN u5' <br /> ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION <br /> 46l. ❑5.STEEL W/COATING <br /> VIL PI PING LEAK DETECTION(C7acckae dat )(A 6a wohne mon'9o�m ABOVEG OUND PIPING <br /> 467.UNDERGROUND PeING <br /> 466. SINGLE WALL PIPING <br /> SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): <br /> PRESSURIZED PIPING(Check all that apply): ;pH TEST <br /> DS [31. ELECTRONIC <br /> LEAK DETECTOR <br /> E <br /> AUTO PUMP <br /> 0 1 ELECTRONIC <br /> LAKDETECTOR 3.0 <br /> "NOFOR LEAK,SYSTEM SYSTEM DISCONNECTION <br /> AND SYSTEM O <br /> FOR LINE LEAK <br /> SYSTEM <br /> +AUDIBLE AND VISUAL ALARMS. <br /> +AUDIBLE AND VISUAL ALARMS. [32. MONTHLY 02 GPH EST <br /> ❑2. MONTHLY 0.2 GPH TEST [3 3 ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS(Check All that apply) <br /> CONVENTIONAL SUCTION SYSTEMS <br /> C3 5DAILY <br /> AL M ON GORING OF <br /> INTEGRITY PUMPING SYSTEM+TRIENNIAL PIPING EI5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> [17. SELF MONITORING (]7, SELF MONITORING <br /> GRAVITY FLOW GRAVITY FLOW(Check all that apply): <br /> ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> ❑S. DAILY VISUAL MONITORING <br /> C19. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): <br /> PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE ANTS VISUAL 10. CONTINUOUS <br /> ANA�(CheckO TURBINESUMPSENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ❑A.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> A. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEMFAILURE AND SYSTEM b.DISCONNECTION <br /> DISCONNECTION (]c NO AUTO PUMP SHUT OFF <br /> "c. NO AUTO PUMP SHUT OFF <br /> 1. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH EST)WTT FLOW SHUT 11, AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION []12. ANNUAL INTEGRITY TEST(0.1 GPM <br /> 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAVITY SYSTEM - <br /> SUCTION/GRAVITY SYSTEM <br /> [3 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENE ORS ONLY(Check VISUAL ALARMS <br /> B that�Y) <br /> EMERGENCY GENERATORS ONLY(Check all that apply) 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS <br /> AUDIBLE AND VISUAL ALARMSUT FLOW <br /> E3 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WIT ❑15.AUTOMATIC I.INELEAK DETECTOR(7.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION 16. ANNUAL INTEGRITY TEST(0.l GPH) <br /> ANNUAL INTEGRITY TEST(0.1 GPH) ❑17.DAILY VISUAL CHECK <br /> 17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT ppILY VISUAL CHECK 46a <br /> 46e. 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE <br /> DATE INSTALLED [32. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 6. NTRTIslC WLINER MONITORING <br /> DISPENSER CONTAINMENT <br /> [13, CONTINUOUS DISPENSER PAN SENSOR i AUTO SHUT OFF FOR <br /> DISPENSER-AUDIBLE AND VISUAL ALARMS <br /> IX.OWNER/OPEKATOR SIGNATURE <br /> 1 certify that the information provided herein'I welld acc 11111111 best of my knowhedge. 470. <br /> SIGNATUREOFOWNER/OPERATOR C DATE: yV <br /> V aR. <br /> �� /7 TITLE OF O R/OP TOR: <br /> NAME OF OWNER/OPERATOR(print): <br /> 477. Psrmit Approved Y Agency use only) 475. <br /> 94. Pemdl Expiration Dale(Agency use only) <br /> Permit Number(Agency we, <br /> Rev.02/16/00 <br /> 6 n MAN-lid bttp://www.unidocs.org <br />