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Fn PROC1R AM rnNCnT.TTIATVD Fn TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of -V1.PIPING CONSTRUCTION(Cheeks] lh apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE VI.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. 1.PRESSURE [12.SUCTION [13.GRAVITY 459. CONSTRUCTION/ D I.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. El 1.SINGLE WALL [195.UNKNOWN 462. MANUFACTURER 2.DOUBLE WALL ❑95.UNKNOWN 2.DOUBLE WALL ❑99.OTHER MANUFACTURER 46L MANUFACTURER 463. ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL [12.STAINLESS STEEL D 7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN [13.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER 0�4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING [19.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING [195.UNKNOWN 465. VII.PIPING LEAK DETECTION.(Check all that apply)(A description ofthc mcnitonng progrmsiretalI be sul miued to the local agrncy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467, PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): PC ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WIT F AUTO PUMP X1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. [12. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST Pq 3. ANNUAL INTEGRITY TEST(0.1 GPH) Pf 3. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 GPH) 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 5(b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF []c. NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION Uf42. ANNUAL INTEGRITY TEST(0.1 GPH) F12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE,AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION [116. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) 17. DAILY VISUAL CHECK 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT ,,-,r DISPENSER CONTAINMENT 468. I. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ts,4. DAILY VISUAL CHECK 469. DATE INSTALLED C]2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING [13. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR E16. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNF,R/OPERATOR SIGNATURE - 1 certify that the information provided h ein is true and ac urate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR DATE: Q$i M r© 6 470, NAME OF OWNER/OPERATOR(print): TITLE OF OWNER/OPERATOR: 472 SAM�EEP �/"4'y 6t h I,nrkftA�K1t Pennit Number(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. 1 Permit Expitation Date(Agency use only) 475. UPCF hwfwrc-b(1/99)-3/4 h"p://www.unidocs.org Rev.02/16/00