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UHIFIED PROGRAl4I CON SOL ICAITEO`r0RM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 P _ V1,PIPING CONSTRUCTION ITJ:eck aC Utat apply) UNOERGROUNO PIPING ABOVEGROUND PIPING SYSTEM TYPE 1 PRESSURE ❑ 2 SUCTION ❑ 3. GRAVITY ® 1. PRESSURE ❑ 2. SUCTION ❑ 7, GRAVITY CONSTRUCTIONt ❑ 1. SINGLE WALL ❑ 3. LINEO TRENCH ❑99 OTHER ® 1. SINGLE WALL ❑95 UNKNOWN MANU5ACTURER lj� 2,DOUBLE WALL ❑95. UNKNOWN ❑ 2 DOUBLE VIALL ❑99. OTHER MANUFACTURER _- IL9 '156=tZ V-h1A..ow 9N MANUFACTURER - ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLEWI 100%METHANOL ❑ 1. BARE STEEL ❑ 8. FRP COAIPATIBLEW 1CQ%METHANOL MATERIALS AND ❑ 2 STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2 STAINLESS STEEL CORROSIEl GALGALVANIZED7. GALVANIZED STEEL PROTECTION ❑ 3.PLASTIC COMPATIBLE WITH CONTENTS 16 95. UNKNOWN ❑ 3. PLASTIC COMPAT19LE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4,FIBERGLASS ❑ 8, PLEXIBLE(HOPE) ❑99. OTHER ❑ 4, FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL w COATING ❑ 9. CATHODIC PROTECTION ❑ 5, STEEL Wf COATING ❑95 UNKNOWN VIL PIPING LEAK.DETECTION(Cheek as that appry) - . . . UNDERGROUND PIPING ABOV EGROUNO PIPING 51NGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Cdeck aU L1at apply): PRESSURIZED PIPING(Check all that applyJ: 1- ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST VATH AUTO PUMP SHUT OFF FOR ❑ A. ELECTRONIC UN-E LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE.AND SYSTEM DISCONNECTION;'-AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0 2 GPM TEST ❑ 2. MONTHLY 0.2 GFH FEST ❑ 3. ANNUAL INTEGRITY TEST(0,1 GPM) ❑ 3. ANNUAL INTEGRITY TEST(0 1 GPM) ❑ {:DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Check am that apply): O S DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING ANO PUMPING SYSTEM TEST(0 I GPM) ❑ 8. TRIENNIAL INTEGRITY TEST(o.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES)N BELOW GROUND PIPING): 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Cheek ail Gnat apply): ❑ 9. 81ENNIAL INTEGRITY TEST 10 1 GPM) ❑ B. DAILY VISUAL MONITORING ❑ 9. SIENNUAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONOARILY CONTAINED PIPING PRESSURIZED PIPING(Check mO Mat apply): PRESSURIZED PIPING(Check ail Nat apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a..AUTO PUMP SHUT OFF VMEN A LEAK OCCURS ❑ tt AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM D,SCONNECTIdN ❑ p, AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION c NO AUTO PUMP SHUT OFF ❑ C NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST IC.I GPH) ❑ 1Z ANNUAL INTEGRITY TEST(0.1 GPM) SUCTSONIGRAVITY SYST=_M: SUCTIONtGRAVITY SYSTEM; C1 13. CONTINUOUS Sum SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chock ae that apply) EMERGENCY GENERATORS ONLY (Check aR that apply) ❑ 14, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3A GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICT.dN ❑ 18.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16. ARNUAL INTEGRITY TEST(D.1 GPM) ❑ 17. DAILY VISUAL CHECK _ _ Q 17- DAILY VISUAL CHECK - VHL DISPENSER CONTAINMENT - OISPENSER CONTAINMENT 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATE INSTALLEtD �J 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER!MONITORING '21 ❑ 1. CONT)NUOUS DISPENSER PAN SENSOR HATH AUTO SHUT OFF FCR DISPENSER•AUDIBLE ANO VISUALALARMS ❑ 8, NONE 1Y.OWNER)dPERATOR.SIGNATURE I Gwo y that kla UHortaanan Pr idsd h--is Uue and accurate 10 Ale bast of my knowledge. -- I TUBE-O, F FUOPERIAT0R CATE or- J'L1ME C CNh4E.RMPERATCR(print} TITLE OF OWNER.OPERATOR ct.L_ 1 � ) Permit Nun;et(For face)use oniyi Permit A€Proved(Fortacal use ant}) Pelma Expiratlon Date(Far kacal use only) CUPAFORM(4199) Fcrmerty SWRCS Fc-