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v � I UNIFIED PROGRAM CONSOLIDATED FORM / G TANKS UNDERGROUND STORAGE TANKS-TANK P Pae Q of VL PIPING CONSTRUCITON(chcJkauthe pply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. ❑L PRESSURE [12.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH ❑99.DIM 460. ❑L SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER ■2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER S4L MANUFACTURER ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑L BARE STEEL ❑6.FRP COMPATIBLE W1100%METHANOL ❑2.STAINLESS STI-FL ❑7.GALVANIZED STEEL ❑2.STAB.7,ESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONSENTS [195.1 7NIINOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HOPE) ❑99.OTHER R 4.FIBERGLASS ❑S.FLEXIBLE(HOPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECHON 464j ❑5.STEL,W/COATING ❑95.UNKNOWN VII.PIPING LEAK DETECTION ack all that )(A of&cmmM : t,esuhmmmtothe" UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING 467_ PRESSURIZED PIPING(Check all thin appy): PRFSSUR12ED PIPING(Check all that apply): 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TESTV1fLI AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEMF.4I.URE,?SIDSYSTEMDISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. [12. MONTHLY 0.2 GPHTESI ❑2 MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) [13. ANNUAL INTEGRITY TEST(0.1 GPH) 04. DAH,Y VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) E15. DAILY VISUAL MONrIORING OF PUMPING SYSTEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPI) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIBNNIALINTEGRHYTFST(o.IGPU) 07. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 07. SELF MONITORING ❑9. B/ENNV,L INTEGRITY TEST(0.1 GPU) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING 09. BIENNIAL INTEGRITY TEST(0.1 GPI) 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 SOW SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check me) ALARMS AND(Check one) N a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 19 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM M b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION (]c NO AUTO PUMP SHUT OFF Oc. NO AUTO PUMP SHUT OFF J111. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION C112. ANNUAL INTEGRITY TEsC(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPI) SUCTION/GRAVITY SYSTEM SUCTTOMGRAVIIY SYSTEM ❑13. CONTINUOUS SOW SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that appy) [114, CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WTTHOTJT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑I5. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16.ANNUAL INTEGRITY TEST(0.1 GPH) [117. DAILY VISUAL CHECK [117.DAILY VISUAL CHECK VIII DISPENSER CONTAINMENT DISPENSER CONTAINMENT ebs. 0 I. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14- DAILY VISUAL CHECK 469. DATE INSTALLED M2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCHILINER MONITORING 3. CONTINUOUS DISPENSER PAN SENSOR WITfI AUTO SHUT OFF FOR oe 0000 DISPENSER+AUDIBLE AND VISUAL ALARMS ❑6. NONE IX.OWNER/OPERATOR SIGNATURE I cerrjfy tha the information provided herein is true and accurate to the best of my inowledge. SI(;NATUREOFOWNER/OPERATOR C-v' T%46r0g- DATE: 1 -0:3 470. n 0- Dj NAW OF OWNER/OPERATOR(plin1): CO'�Ti'TLN.S Do✓ TITLE OF OWNER/OPERATOR Co nl4Aa 01 oma- 472. � ,�, W•vf• '32o e •; - t eLa�e �� Cowes Permit Number(Agency use only) 473. Permit Approved By(Agency use mly) 474. Permit Expiration Dwe(Agracyase only) 475.