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FEB-23-2007 09 : 14 AM - P' 12 UNIFIED PROGRAM CONSOLIDATED FORM TANK: 023IN8 PR X: PRD232388 01 FAC M: FABW]6B7 UNDERGROUND STORAGE TANKS - TANK PAGE 2 T)j� VLPIPHVGCONSTRUCTION(cm -1)0utpay) Pw9d7 UNDERGRO90-P-1PINZ ABOVEGROUND PIPING SYSTEM TYPE ® L PRESSURE ❑2.SUCTION ❑ 3.GRAVITY 459 I,PRESSURE ❑2.SUCTION ❑3.GRAVITY u9 CONSTRUCTION ❑I.SINGLE WALL ❑3.LINEDTRENCH ❑99.OTHER 160 ❑ I.SNOLE WALL ❑95.UNKNOWN 461 ®2.DOUBLE WALL MM.UNKNOWN a61 ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER MANUFACTURER ❑ 1 BARE STEEL ❑6.PRP COMPATIBLE w laat METHANOL ❑ I,BARE STEEL ❑C PRP COMPATIBLE w11P9N METHANDL ❑ 2.STAINLESS STBEL a 7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑ 7,OALVANIZP.DSTEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑M UNKNOWN ❑ PLASTIC COMPATIBLEWICONTBNTS ❑ 95 UNKNOWN M 4.FIBERGLASS ❑ S.PLEk1uL3(RDPg) ❑99,OTHER Q 4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑ 99 OTHER ❑ s,STEEL WICOATINO ❑ 9.CATHODIC PROTECTION 444 Q 5,STEEL W/COATING ❑ 9.CATHODIC PROTECTION VO.PIPING LEAKDETECTION Chea Jl Rna A tkxeruN mawo' wIl h4,ubMummwbal ) UNDER R UN PINABOVE ROVNDPIPIN SINIGLE WALL PIPING 466 SING LEWALLPIFNG w7 PREMORIZED PIPING(Cha,all Na:apply). PRESSURIZRD PIPING(Check all that apply)i QI.ELECTRONIC LINE LEAK DETECTOR 30 OPH TEST WRI3AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TESTWITH AUTO PUMP SHUT OFF MR LEAK SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK.SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS, ❑2 MONTHLY O 2 GPH TEST ❑2.MONTHLY 0.2 OPHTEST ❑ 3.ANNUAL INTEGRITY TEST III.I DPN) ❑3,ANNUAL INTEGRITY TEST(0.1 OPH) [14 DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Chalk US that apply) ❑ S.DAILY VISUAL MONTTORNO OF PUMPING SYSTEM ITRIENNIEAL PIPING ❑ 3.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEBT(0.I OPH) ❑6.TRIENNIAL INTEGRITY TEST(0.1 OPH) SAn SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING), San SUCTION SYSTEMS(NO YALU BE IN BELOW GRDUNDPGTNC). [17.SELF MONITORING ❑ L SELF MONITORING GRAVITYPLOW ❑9.R®l4NIAL INTEGRITY TEST(DL I)OPH GRAVITY PLOW(Cheek all that ppplY)I ❑S.DAILY VISUAL MONITORING Q 9,BIENNIAL INTEGRITY TEST(0 1)GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRTSBUR6ED PIPING(Cheek all,hat apply): PRESSURIZED PIPING(Cheek ell that apply). 10.CONTINUOUS TURBINE SUMP SENSOR W=AUDIBLE AND VISUAL I0.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLR AND VISUAL ANDH,aat, N ALARMSAND(Chmka AUTO PUMP SHUT OFF WHIN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS O PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑9, NO AUTO PUMP SHUT OFF ❑ e. NOAUTOPUMPSHUTOPF Q I1,AUTOMATIC LUNE LEAK DETECTOR(3 0 OPH TEST)WITH FLOW SHUT OFF OR ❑ H.AUTOMATIC LEAK DETECTOR RESTRICTION Q 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEOR)TY TEST(0,1 OPH) SUCI1014/GRAVTIY SYSTEM SUCTTON/GRAVTTY SYSTEM ❑ U.CONTINUOUS SUMP SENSOR�AUDIBLE AND VISUAL ALARMS ❑ 13,CONTINUOUS SUMP SENSOR*AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Oaak e1I.hR aPph) EMERGENCY GENERATORS ONLY(Chet 4 prtw*) ❑ 14,CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOGT ALrrO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLS AND VISUAL ALARMS ❑ LI AUTOTOMATICINEL A AK DETECTOR(3,O OPs1 TEM WITHOU FLOW ❑ IS. UT ORIC LINE LEAK DETECTOR(3.0 OPH TEST)WITHOUT FLOW L ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16,ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ IT DAILY VISUAL CHECK VII.DIEPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I,).COAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUALCHECK (+ DAtE INSTALLED 16Y EONTNVOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑S.TRENCH LINER I MONITORING CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR Q 6 NONE 7 O 7 " �ISPENSER+AUDIBLE ANDYISUALALARM3 Iw 169 IX OWNEJU45PERATOR SIGNATURE 1 oPPlk wtuR IeRA6Rlan H9Yke2Male butte,p6 a:C.Ntea Rxbgl NNY paw 91 A RB OFOWNE DE TOR DATE /tom 174 NAME OF OWNER/OPEM ) TITLE OF OWNER/OPERATOR r 4n MANAWNG MEMBER In Emma Nm.be @n Neel we m:y) 4b Na It APpm (Pee lmN me my) 474 P.."E,". eIN.(P.,lmN... 475 PT0003729 EEOOOOS17 12/31/2006 12:00:OOAM VPCF(12/99 revised) \I NII