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UNDIED PROGRAM CONSOLIDATED FORM <br /> TANKS �l� <br /> UNDERGROUND STORAGE TANKS- TANK PAGE 2 <br /> Pae of <br /> VL PIPING CONSTRUCTION(cleetau ea .,*) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE M 1.PRESSURE D 2.SUCTION D 3.ORAVTTY 458. D 1.PRESSURE D 2.SUCTION D 3.GRAVITY 459. <br /> CONSTRUCTION/ D 1.SINGLE WALL D 3.LINED TRENCH D 99.TITHE 460. D 1.SINGLE WALL D 95.UNKNOWN 46z_ <br /> MANUFACTURER W2.DOUBLE WALL [195.UNKNOWN D 2.DOUBLE WAIL D 99.OTHER <br /> MANUFACTURER 'T N 46L MANUFACTURER 46s. <br /> ❑1.BARE STEEL D 6.FRP COMPATIBLE W/100'/METHANOL D 1.BARE STEEL D 6.FRP COMPATIBLE W/100%METHANOL <br /> D 2.STAINLESS STEEL D 7.GALVANIZED STEEL D 2.STAINLESS STEEL D 7.GALVANIZED STEEL <br /> D 3.PLASTIC COMPATIBLE WITH CONTENTS D 95.UNKNOWN D 3.PLASTIC COMPATIBLE W/CONTENTS D 8.FLEXIBLE(HDPE) D 99.OTHER <br /> H 4.FIBERGLASS D S.FLEXBLE(HOPE) D 99.OTHER D 4.FIBERGLASS D 9.CATHODIC PROTECTION <br /> D 5.STEEL W/COATING D 9.CATHODIC PROTECTION 464. D 5.STEEL W/COATING D 95.UNKNOWN 465. <br /> VIL PIPING LEAK DETECTION(cb�k an daa )(p 'm orthe moatbm�g sueuxa�bmlu iwuu wd ee�.y.) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466- SINGLE WALL PIPING 467. <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> D 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST YM AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST. 'M AUTO PUMP <br /> SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> +AUDBIE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. <br /> 02. MONTHLY 0.2 GPH TEST 02. MONTHLY 0.2 GPH TEST <br /> 03. ANNUAL IN rEGlUTY TEST(0.1 GPH) D 3. ANNUAL INTEGRITY TEST(0.1 GPH) 1 <br /> 04- DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> D 5. DAILY VISUAL MONITORING OF PIMPING SYSTEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 OM <br /> SAFE SUCTION SYSTEM(NO VALVES IN BELOW GROUND PIPING): D6. TRIwNL4LINTEGRITYTEST(m GPH) <br /> D7. SELF MONITORING SAFE SUCTION SYSTEMS IN VALVES INBELOW GROUND PIPING): <br /> GRAVITY FLOW D7. SELF MONITORING <br /> E39. BIENNIAL INTEGRITY TEST(0.i GPNI) GRAVITY FLOW(Check a6 that apply): <br /> 08. DAILY VISUAL MONITORING <br /> 09- BIENNIA.INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> In. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SOW SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Cheek one) <br /> ®a. AUTO PUMP SHUT OFF WHEN A TEAK OCCURS AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> M b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEMAUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Oc NOAUTOPUMPSIRROFF De. NOAUTOPUMPSHUTOFF <br /> Bit. AUTOMATICLINE LEAK DETECTOR(3,0 GPH TEST)WI'TIL FLOW SHUT AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> D 12, ANNUAL INTEGRITY TEST(0.t GPH) 12. ANNUAL INTEGRITY TEST(0.1 GPM <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> D 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS D 13.CONTINUOUS SOW SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> 014. CONTINUOUS SUMP SENSOR AUTO PUMP SHUT OFF D 14. CONTINUOUS SUMP SENSOR�lIITOCU AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) Wf�IiO� FLOW <br /> SHUT OFF OR RESTRICTION ❑ 15.AUTOMATIC LINE TEAK DETECTOR(3.0(3PH TEST) <br /> 016. ANNUAL INTEGRITY TEST(0.1 GPH) D 16. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> D 17. DAILY VISUAL CHECK D 17.DAILY VISUAL CHECK <br /> VII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 468. 01, FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE D 4. DAILY VISUAL CHECK 469. <br /> DATE INSTALLED 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D 5. TRENCH/LINER MONITORING <br /> O _ D 3. CONTINUOUS DISPENSER PAN SENSOR AUTO SHUT OFF FOR D 6. NONE <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> '�✓ IIT.OWNFWOPERATOR SIGNATURE <br /> I calt64at the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF OWNER/OPERATOR DATE: I�• 470. <br /> n G 1n.0 g d -C` <br /> NAME OF OWNER/OPERATOR(pnnt: o OF OWINER/OPERATOR: r-0- 0(1_ 4M' <br /> r�C O W I^ 1kennA CDR L.'. V N 4\L <br /> Pewit Ntmber(Agency useo y erma roved By(Agency ase only) 474. Parch Ezlsrabon Date <br /> (Agency use only) 475. <br />