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OIFIED PROGRAM CONSOLIDATED FOR* TANK: TA0505871 PR #: PR0505867 UNDERGROUND STORAGE TANKS - TANK PAGE 2 FAC #: FA0007059 VI. PIPING CONSTRUCTION (Check all mat apply) pwy nap UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE %LPRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 CONSTRUCTION ❑1. SINGLE WALL ❑3.LINEDTRENCH ❑99.OTHER 460 ❑1. SINGLE WALL El 95. UNKNOWN 462 22.DOUBLEWALL ❑95. OWN ❑2. DOUBLE WALL ❑99.OTHER MANUFACTURER .0 a 461 MANUFACTURER 463 ❑ 1. BARE STEEL 6. FRP COMPATIBLE W IWA MEITANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W 10MMEDIAN06 ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN ❑ PLASTICCOMPAT03LEW/CONTENTS ❑ 95. UNKNOWN 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99.OTHER ❑ 4. FIBERGLASS ❑ S. FLEXIBLE (HDPE) ❑ 99. OTHER Im 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 4" ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 466 VO. PIPING LEAK DETECTION (Cberkall wt apply)(A uaaipmnormem®itorinapmsamahal ne:nb:mmato me local .amey.> UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING PRESSURIZED PIPING (Check all that apply): 467 PRESSURIZED PIPING (Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 2. MONTHLY 02 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST (O.I GPH) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIF.AL PIPING ❑ S. DALLY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST (0.1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS (NO VALUES IN BELOW GROUNDPIPING): ❑ 7. SELF MONITORING E]7. SELF MONITORING GRAVITY FLOW ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH GRAVITY FLOW (Check all that apply): ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNW INTEGRITY TEST (0.1) GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING (Check ell 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 (Choir.) ALARMS AND (LTnY me) aa. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ,r-1 b. 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 SHUTOFF ❑ C. NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 12. 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 (Chale all mnt ratty) EMERGENCY GENERATORS ONLY (Chs k at nen apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF • ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF a AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ V. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VITT. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER / MONITORING V.3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6. NONE DISPENSER + AUDIBLE AND VISUAL ALARMS 469 IX. OWNER/OPERATOR SIGNATURE I a:fiFy thatthe mhmerian pmvidcdh erin is true and amuale m tiwban orrryq:oWlodge. SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR (print) TITLE OF OWNER/OPERATOR 471 472 Pemut Nunha(F9rlaalaaeonly) 473 Pcmdl AWmeI(Fmka1mcon]Y) 474 Fond Expiration Date(Forloal use only) 475 PT0011900 EE0000817 12/31/2003 UPCF (12/99 revised)