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• UNIFIED PROGRAM CONSOLIDATED FOI /�� TANK: T'A0184806 (J PR 8: PR0231848 FAC N: FA0002052 UNDERGROUND STORAGE TANKS-TANK PAGE 2°"e VL PIPING CONSI'RUCT'ION(cb«krill d,at npph) Pagc3 of3 as UNDERGROUND PIPING ABOVEGROUND PIPING SYST'E61 TYPE ❑ I.PRESSURE ®2.SUCr10N ❑ 3.GRAVI I'Y 458 ❑ I.PRESSURE ❑2.SUCTION ❑3.GRAVI rY 439 CONSTRUCTION ❑1.SINGLE WALT. 03 LINEDTRF.NCH [199.OTHER .4w ❑ I SINGLEWALL L ❑95 UNKNOWN 462 DOUBLE WAIL 0/5.UNKNOWN ❑2.DOUBLE WAIL [:199,OTHER MANUFACTURE IC JG1 MANUFACTURER 463 ❑ 1.BARE STEEL ❑6.FRP COMPArIBLL•W ION.Mill HANOL ❑ 1.BARE;STEEL ❑6.FRP COMPATIBLE w 100%METHANOL ❑2.STAINLESS S'fEE:L ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ® 95.UNKNOWN ❑ PLASTIC COMPATj LL W/CON TENTS ❑95.UNKNOWN ❑4.FIBERGLASS El B.FLEXIBLE(HDPE) ❑99.OTHER ❑4 FIBERGLASS , [I B.FLEXIBLE(HDPE) C1 99 O'fliE-.R ❑5.STEEL W/COATING ❑9 CATHODIC PROTECTION 404 ❑ 5.STEEL W/COATING ❑9 CATHODIC PROTECTION 465 VII.PIPING LFAK DET'F,CTION(Cheek all mat apply)(A cWcnlaion of(lie momtorin•pro• m shall bo submiucd to the local agco-) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING pea SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all(list 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-f-AUDIBLE AND FOR LEAK.SYSTEM FAILURE,AND SYSTEM DISCONNEC11ON+•AUDIBLE AND VISUAL.ALARMS. VISUAL.ALARMS. 2.NIONTHI.Y 0.2 GPH TEST ❑2.MONTHLY 0.2 GPH TEST ❑3 ANNUAL_INTEGRITY TEST(0 1 GPH) J 3 ANNUALINTEGRI'rYTEST(01 GPH) ❑4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL.MONITORING OF PUMPING SYSTEM+TRIENNIL'AL PIPING ❑ 5.DAILY VISUAL.MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑&TRIENNIAL INTEGRITY TEST(0.1 GPH) J. MX SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING)t SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROONDPIPING): FLF MONITORING ❑7.SELL'MONI'T'ORING GRAVITY FLOW ❑9 MENNIAL INTEGRITY'TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑B DAILY VISUAL MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1)GPII 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(Check av) ALARMS AND(Click ato) ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑b.AUTO PUMP SNOT 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 I.INF LEAK DETECTOR(3.0GPIt TEST)WITH FLOW SHUT OFF OR ❑ 11.AU rOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL,INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAI,INTEGRITY TFS'T(O.L GPH) SU CTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 3.CONTINUOUS SUMP SENSOR+AUDIBLE.AND VISUAL.ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL.ALARMS EMERGENCY GENERATORS ONLY(C1,eck all that apply) EMERGENCY GENERATORS ONLY(Chak all 1hat:ry,pll9 ❑ 14 CONTINUOUS SUMP SENSOR W TH UT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WrPHOUT AUTO PUMP SHUT OFF� AUDIBLE AND VISUAL.ALARMS AUDIBLE AND VISUAL ALARMS 15.AUTOMATIC LINE LEAK DETECTOR 0.0GPH TEST)WI'T'HOUT FLOW ❑ 15.AUI.OMATIC LINE.LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ S HUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAI.INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17,DAILY VISUAL C141-ICK ❑ 17.DAILY VISUAL CHECK VIII,DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I.I:LOA"T MI:CliANISM'1'l1A I'SItUTS OFI'Sfll::AR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 4G8 ❑2.CON1'INl10US DISPENSER PAN SENSOR*AUDIBLE AND VISUAL ALARMS ❑5.7RL•NCI1 LINER/MONITORING ❑3.CON"1'INUOUS DISPENSER PAN SENSOR WITH AU-1.0 SHUT"01'1'I'OK � '\NONE DISPENSER AUDIBLE:AND VISUAL.ALARMS 169 IX.OWNER/OPERATOR SIGNATURE I cenifav that the'fmwtion prondad herein is inwaWNimtc wk best of n,s•knowledge. SIGN 'U •OFOWNF.Wd1PI:RATOR DATE !y n� `Q 170 NAAIGOPO NEWOPFRA'fOR�pnnt) i 11TfLpPOWNF.IIUOP`FRR TT_TORS ' m J e r 47I e- r vZ r.(/, a eLA 47t Pam.,Number(Fm]Deal use only) 475 Perm.l Approred(For local use only) 474 Pem,it a pirwiw Dae(For local use ony) 475 PT0002044 EE0003804 12/31/1.997 12:00:OOAM UPCI'(12/99 revised)