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I Ij,n PRn(_RAN4 r0NC0T.TDATFD F011 <br />TANKS <br />UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br />Pagc <br />VLPIPING CONSTRUCTION' (check all that apply) ' of <br />UNDERGROUND PIPING ABOVEGROUND PIPING <br />SYSTEM TYPE L PRESSURE D 2. SUCTION D 3. GRAVITY 45e. 1. PRESSURE ❑ 2. SUCTION D 3. GRAVITY 459. <br />CONSTRUCTION/ 1, GLE WALL 113. LINED TRENCH [199. OTHER 460. ❑ 1. �LGLE WALL <br />MANUFACTURER , 4X `DOUBLE WALL [195. UNKNOWN _ / ❑ 95. UNKNOWN 462. <br />Od'2 DOUBLE WALL ❑ 99. OTHER <br />MANUFACTURER <br />461. <br />MANUFACTURER <br />463. <br />❑ 1. BARE STEEL D 6. FRP COMPATIBLE W/100% METHANOL <br />❑ 2. STAINLESS STEEL [17. GALVANIZED STEEL <br />❑ 3. f,LASTIC COMPATIBLE WITH CONTENTS 1195 UNKNOWN <br />4. FIBERGLASS [:18. FLEXIBLE (HDPE) D 99. OTHER <br />D 5. STEEL W/COATING D 9. CATHODIC PROTECTION 4&1 <br />❑ 1. BARE STEEL <br />D 2. STAINLESS STEEL <br />❑ 3. PLASTIC COMPATIBLE W/ CONTENTS <br />D 4. FIBERGLASS <br />D 5. STEEL W/COATING <br />D 6. FRP COMPATIBLE W/100% METHANOL <br />D 7. GALVANIZED STEEL <br />❑ 8. FLEXIBLE (HDPE) 1199. OTHER <br />D 9. CATHODIC PROTECTION <br />[195. UNKNOWN 465. <br />UNDERGROUND PIPING <br />SINGLE WALL PIPING 466. <br />PRESSURIZED PIPING (Check all that apply): <br />D 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br />SHUT-OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION <br />+ AUDIBLE AND VISUAL ALARMS. <br />[12. MONTHLY 0.2 GPH TEST <br />03. ANNUAL INTEGRITY TEST (0.1 GPH) <br />CONVENTIONAL SUCTION SYSTEMS <br />D 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING <br />INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />D 7. SELF MONITORING <br />GRAVITY FLOW <br />09. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />ALARMS AND (Check one) <br />❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />D b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />Dc. NO AUTO PUMP SHUT OFF <br />11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WIT x FLOW SHUT <br />�/� OFF OR RESTRICTION <br />I7� <br />Ir ". ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />[113. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />[114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br />AUDIBLE AND VISUAL ALARMS <br />[:115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) W THOUT FLOW <br />SHUT OFF OR RESTRICTION <br />D 1166 1ANNUAL INTEGRITY TEST (0.1 GPH) <br />hd'17. DAILY VISUAL CHECK <br />SINGLE WALL PIPING 467. <br />PRESSURIZED PIPING (Check all that apply): <br />0I ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br />SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION <br />+ AUDIBLE AND VISUAL ALARMS. <br />[12. MONTHLY 0.2 GPH TEST <br />03. ANNUAL INTEGRITY TEST (0.1 GPH) <br />04. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS (Check all that apply) <br />05- DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />[16. TRIENNIAL INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />07. SELFMONITORING <br />GRAVITY FLOW (Check all that apply): <br />E18. DAILY VISUAL MONITORING <br />09. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />ALARMS AND (Check one) <br />D a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />D b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />Dc. NO AUTO PUMP SHUT OFF <br />D IL AUTOMATIC LEAK DETECTOR <br />D 12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />D 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />[114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br />AUDIBLE AND VISUAL ALARMS <br />[115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) <br />D 16. ANNUAL INTEGRITY TEST (0.1 GPH) <br />[117. DAILY VISUAL CHECK <br />' rcnm. numoer (Agency use only) 473. I Permit Approved By (Agency use only) 474. I Permit Expiation Date (Agency use only) 475. <br />umr nw)wrc-o (1/99)-3/4 http://www.unidocs.org Rev. 02/16/00 <br />Vlll. DISPENSER CONTAINMENT <br />DISPENSER CONTAINMENT <br />468. <br />1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DAILY VISUAL CHECK 469. <br />DATE INSTALLED <br />[12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D 5. TRENCH/LINER MONITORING <br />D 3. CONT OUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR <br />DISPE ER+AUDIBLE AND VISUAL ALARMS D 6. NONE <br />IX. OWNER/OPERATOR SIGNATURE <br />I certify that the informati <br />r i h cin i accurate to the best of my knowledge. <br />SIGNATURE OF OWNER/OP <br />A <br />DATE: 01-05"7D <br />-05"7 1 470. <br />NAMEOFOWNER/OPERAT <br />( - I I((/„{lA IJ/I _ <br />TITLE OF OWNER/OPFRATORA I S. 472. <br />' rcnm. numoer (Agency use only) 473. I Permit Approved By (Agency use only) 474. I Permit Expiation Date (Agency use only) 475. <br />umr nw)wrc-o (1/99)-3/4 http://www.unidocs.org Rev. 02/16/00 <br />