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�IFIED PROGRAM CONSOLIDATED FORIO TANK: TA0507994 PR#: PR0231233 FAC#: FA0002479 UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI.PIPING CONSTRUCTION(chskaR not apply) Page 5 of 5 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE ❑ 2.SUCTION ❑3.GRAVITY 459 CONSTRUCTION 1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.GIBER 460 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 462 .DOUBLEWALL 1195.UNKNOWN ❑ 2.DOUBLE WALL 99.OTHER MANUFACTURER � 461 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 ❑7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/C NTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLEW/CONTENTS ❑ 95.UNKNOWN ❑4.FIBERGLASS 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VD.PIPING LEAK DETECTION(cnak an that apply)(A dmmipEon ofineanomitorinaprottatn m ll1,cs mmitra4 to Ra to it atway.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): 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 ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5.DAILY 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 ❑ 7.SELF MONITORING GRAVITY FLOW ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ 8.DAILY VISUAL MONITORING ❑ 9.BIENNIA.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(Ch konc) ALARMS AND(C one) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS �pfP It.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 SHUT OFF ❑ C.NO AUTO PUMP SHUT OFF 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR y(RESTRICTION �a 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(Check A that appy) EMERGENCY GENERATORS ONLY(Check all wt appy) ❑ 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 ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SRUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VDI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 1. E]FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 4.DAILY VISUAL CHECK DATE INSTALLED 168 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING (Q G$ ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE l DISPENSER+AUDIBLE AND VISUAL ALARMS 469 DC.OWNER/OPERATOR SIGNATURE I artiry not r 'nvrot'IhELeemu o-ue aM a¢male to Webest ormy lmowlNgc SIGNAT PERATOR DATE I,Ppe( �� 470 NAME OteWNERJOPERATOR(prin0 TITLE OF OWNER/OPERATOR 4n 472 Pmnit?J m or(Forlanlmeony) 473 Permit App ocI(Fw10 mconh) 474 Permit Expiration Darr(For local me only) 495 PT0002471 EE0000646 6/30/2003 UPCF(12/99 revised)