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Adilla 144602 UNIFIED PROGRAM CONSOLIDATED FORM TANK: PR0 PR#: 023144631446 FAC#: FA0000853 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(check Hl tAa apply) Pae,3 of3 UNDERGROUND PIPING ABOVEGROUND PIPING 459 SYSTEM TYPE ❑ 1.PRESSURE El2.SUCTION ❑ 3.GRAVITY 459 ❑ I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY CONSTRIILTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 460 ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 462 ❑2.DOUBLE WALL 095.UNKNOWN 461 El2.DOUBLE WALL ❑ 99.OTHER 463 MANUFACTURER ER ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE wl Ia METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/I I0,.METH V i0L ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL [I 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS [-] 95.UNKNOWN E] PLASTICCOMPATIBLEW/CONTENTS ❑ 95.lINKNOWN ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VR.PIPING LEAK DETECTION(Chrk91 matopply)(Aa,scOneofthatnNiirorAgInc8nanSWI heaamanm rom,local agea ) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PWING 466 SINGLE WALL PIPING d67 PRESSURIZED PIPING(Cheek.11 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 O LEAN.SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND 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(Cheek all that apply) CONVENTIONAL SUCTION SYSTEMS ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING 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 GRAVITY FLOW(Check all that apply): ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH ❑ S.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 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check arc) ALARMS AND(Chcckaa) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ A.AUTO PUMP SINT OFF WHEN A LEAK OCCURS E] b.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 RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM ❑ 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(aeck all mat appy) EMERGENCY GENERATORS ONLY(Ch k all that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' ❑ 14.CONEANDVISUSUMP ALARMS WITHOUT AUTO PUMP SHUT OFF " AUDIBLE AND VISUAL ALARMS ❑ I5.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW E] 15.AUTOMATIC RESTRICTION L AR DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ V.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VM.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED ms ❑ 2,CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1caify Out me infwmrioo peniddha,lou trv,and amaate to 0u bear ofny mw Wge 470 SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 4]I 472 Pmdt Nu ba(Forlor .a My) 473 PantAppnvcd(Fne1.I.ccAIy) 474 PemutP pinion Mte(Forl.1 ave Dory) 475 PT0000852 EE0000817 6/30/2004 UPCF(12/99 revised)