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iW TTNIFIRII PR/N7R AM(`nNR(YT.III ATF.D F(IR TANKS UNDERGROUND STORAGE TANKS-TANK PAGE 2 Pa e of VL PIPING CONSTRUCTION(Check all that ) ADOVEGROUNDPIPING UNDERGROUND PIPINGLPRISSURE ❑2.SUCTION ❑3.GRAVITY 459. SYSTEM TYPE58.[Ti.i.PRESSURE ❑2.SUCTION ❑3.GRAVITY 460 1 SINGLE WALL 95.UNKNOWN 461 CONSTRUCTION/ ❑1„6INGLE WALL ❑J.LINED TR11CH ❑99.GTHER �I10UBLE WALL [399 OTTER MANUFACTURER 2.DOUBLE WALL ❑95.UNKNOWN IRER 463. 46i. MANUFACR MANUFA(.T mc' ❑6.FRP COMPATIBLE W/100•/.METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE WH00%METH4:vOL O I.BARE LLESS SEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL S. [3 3 LASTIC COMPATIBLE WITH CONTENTS ❑95.UNTCVONN 3.PLASTIC 4.FIBERGLASSMPATBLEWI CONTENTS O 9.CATHOD C(I ❑99.OTHER PROTECTION 4.FIBERGLASS ❑8.FLEXIBLE(HOPE) ❑99.OTHER 095.UNKNOWN 46s. 1:15.STEEL W/COATING ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTIONshah mbmined kcal VII.PIPING LEAK DETECTION Icveck a0 da ly) Aaa 1p°0Id1C"10°° ABOVEGROUND PIPING UNDERGROUND PIPING �7' 466. SINGLE WALL PIPING SIN E WALL PIPING PRESSURIZED PIPING(Check all that apply): PR IRIZED PIPING(Check all Out apply): ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST ALTO PUMP 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST wlrtl AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT-OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCOSNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. C]2. MONTHLY 02 GPH TEST ❑2. MONTHLY 0.2 GPH TEST 03. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) [34.- DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all Out apply) CONVENTIONAL SUCTION SYSTEMS ❑5 *1 GPH) G OF PUMPING SYSTEM+TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PANG AND PUMPING SYSTEM . DAILY VISUAL INTEGRITY TEST(0 SAFE SUCTION SYSTEMS(NO VALV�SINBELOW GROUND PIPING): SFE SUCTION SYSTE MS(NO VALVES BELOW GROUND PIPING): [17. SELF MONITORING 07. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) [3 g DAILY VISUAL MONITORING [39. BIENNIALINTEGRITY TEST(O.l GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all Out apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE A,D VISUAL to. ALANOINE AND(Che TURBINESUMPSENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check once) [I a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ,Q a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO F��O OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF �c. NO AUTO PUMP SHUT OFF II AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)u_L FLOW SHUT 11.AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ❑12 ANNUAL INTEGRITY TEST(0.1 GPH) 12. ANNUAL I TTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM Il.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑IJ. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALAP%I EMERGENCY ERGENCY GENERATORS ONLY(Check all Out apply) EMERGENCY GENERATORS ONLY(Check all thalJTO PUMP SHUT OFF 13 14 CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑I5.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION 0 16,ANNUAL INTEGRITY TEST(0.1 GPH) ANNUAL INTEGRITY TEST(0.1 GPH) ❑17,DAILY VISUAL CHECK 17. DAILY VISUAL CHECK Vm.DISPENSER CONTAINMENT DAILY VISUAL CHECK 469. DISPENSER CONTAINMENT 469. 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATE INSTALLED ❑2. CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 6. NONE DISPENSER-AUDIBLE AND VISUAL ALARMS IX.Oa ER/OPERATOR SIGNATURE 1 certify that Ne information provided herein' e and accurate 10 tl1e 10 my knowledge. L 470. SIGNATURE OF OWNER/OPERATOR DATE: D / 472. NAME OF OWNER/OPERATOR(print): 1/( I L /J (/] TITLE OF0 ROPE TOR: O I _ 473,. Permit ApPm"ed BY(ASSY we only) a4 Permit Expiration Date(Agency use only) 475. Permit Number(Agency we only) Rev.02/16/00 .n roor_are http:/Iw .unidocs.org