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a FIED PROGRAM CONSOLIDATED FORM• TANK: TA0507939 PR#: PR0231074 FAC#: FA0002541 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPING CONSTRUCTION(Clack all wa apply) Pages ors UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE ❑ 2.SUCTION ❑3.GRAVITY 458 ❑ 1.PRESSURE ❑2.SUCTION [13.GRAVITY 459 CONSTR=M 1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 460 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 462 [ ,2.DO LE WALL ❑95.UNKNOWN` E-1 2.DOUBLE WALL ❑ 99.OTHER MANUFACTURER p'j' i yV 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/10%METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/1 W%METRANOL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/�CLpNTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE WI CONTENTS ❑ 95.UNKNOWN ❑ 4.FrBERGLAS: S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑99.OTHER ❑ 5.STEEL W/COATING LLF4JJ••9.CATHODIC PROTECTION a64 ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(Clack all wt apply)(A ee,ctiptim or4a mmiwwy program stun ba aaxnamal w ma kcal agency) 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 GPM TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPM 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 GPM TEST ❑ 2.MONTHLY 02 GPM TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING [15.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPM ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPM) 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)GPM GRAVITY FLOW(Check all that apply): ❑ 8.DAILY VISUAL MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1)GPM 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(Cherk aa) ALARMS AND(Chink one, ❑l a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ' DaNb.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM I 'DISCONNECTION 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 ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) 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(Cbcak ell mal apply) EMERGENCY GENERATORS ONLY(Gerd all tint apply) ❑ 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 GPM TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATEINSTALLED 4682.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING XEJ 3.I �� DISPENSER AL ALARMS CONTINUOUS +AUDIBLDISPENSER AND VI USENSOR HAUTO SHUT OFF FOR ❑ 6.NONE 469 IX.OWNER/OPERATOR SIGNATURE I umrymal ati mri4a4 hcran isuucaMaumemwilcbatdr lcowladgc. SIGMA F E ERATOR DATE 470 Bob DeNinno -7ho2, NAM OWNER/OPERATOR(prfat) TITLE OF OWNER/OPERATOR Environmental Manager 1, 472 PecmitNmnber(Fmkcaia wly) 473 Pemul Appuvc1(Fwkcaluuady) 474 P=it Expiration Dac(Fm local me oay) 475 PT0002533 EE0000646 6/30/2003 UPCF(12/99 revised)