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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE- C3 1 PRESSURE 112. SUCTION 3 GRAVITY X1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ 1 SINGLE WALL ❑ 3. LINED TRENCH ❑99 OTHER ❑ 1. SINGLE WALL 1195 UNKNOWN MANUFACTURER ❑ 2 DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER ❑ 1 BARE STEEL ❑ B. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL El 7. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95 UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8 FLEXIBLE(HDPE) ❑99. OTHER ❑ 4 FIBERGLASS ❑ B. FLEXIBLE(HDPE) ❑99 OTHER. ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 5STEEL W/COATING ❑95. UNKNOWN VII.PIPING LEAK DETECTION tCheck all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check as that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK. LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION;AUDIBLE AND VISUAL ALARMS ALARMS ❑ 2. MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY G 2 GPH TEST El 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.TRIENNIAL PIPING INTEGRITY 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0 1 GPH) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SSA/FE SUCTION SYSTEMS(NO VALVES'IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): lZ0 7 SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): El BIENNIAL INTEGRITY TEST(0 1 GPH) IPf 8 DAILY VISUAL MONITORING ❑ 9 BIENNIAL 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 ALARMS AND (Check one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) ❑ a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b AUTO PUMP DISCONNECTION OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION -1c. 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 RESTRICTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ 12 ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTIONIGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM' ❑ 13 CONTINUOUS SUMP SENSOR.AUDIBLE AND VISUAL ALARMS ❑ 13 CONTINUOUS SUMP SENSOR F AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF♦,'AUDIBLE AND VISUAL VISUAL ALARMS ALARMS ' ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 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 DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUAL ALARMS ❑ 8. NONE IX.OWNER/OPERATOR SIGNATURE I cattily that the infqrmatyrprovided h rein is t nd accurate to the bast of my knowledge SIGNATURE DATE / S- zg00 NAME FR/OP ATOR/tint) TITLE OF O ER/OPERATOR z5NvIltW ,,70-,! Nl7W FAY Permit Number(For local use only) Permit Approved(For local use only) Penny)Expiration Date(For local use only) CUPAFORM(4/99) Formerly SWRC8 Form 8