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UNIFfED PROGRAM CONSOLIDATED FORM U TANKS Iv1f n� UNDERGROUND STORAGE TANKS -TANK P 2 Y Pae of 2 VL PIPING CONSTRUCTION(c"alithc UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 0 1.PRESSURE ❑2.SUCTION ❑3.GRAVITY ass. ❑L PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ ❑1.SINGLE WALL ❑3.LINED TRENCH [199.OTHHE R 460. ❑L SINGLE WALL ❑95.UNKNOWN �. MANUFACTURER ■2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 'i " 461. MANUFACTURER 463. Cl 1.BARE STEEL ❑6.FRP COMPATffiIE W/100%METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS [18.FLEXIBLE(HDPE) ❑99.OTHER M 4.FIBERGLASS ❑8.FLEXIBLE(HOPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECHON 464. ❑5.STEEL W/COATING ❑95.UNKNOWN abs. VII PIPING LEAK DETECTION(chcia nal )(A oTa¢a rmane Ana etmmu�laa UNDERGROUND PIPING - ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WJH AUTO PUMP ❑L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SF_ITT OFF FOR LEAK,SYSTEMM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. ❑2. MONTHLY 02 GFH TEST ❑2. MONTHLY 0.2 OPHTEST ❑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 [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.I GPH) SAFE SUCTION SYSTEMS(NO VALVES INBELOW GROUND PIPING): 06. TRIENNIALITTITGRITYTEST(OAGPH) 07. SELFMONITORING SAFE SUCTION SYSTEMS(NO VALVES INBELOW OROUNDPIPING): GRAVITY FLOW ❑7. SELFMONITORING [19, BIENNIAL LNTEGRITY TEST(0.1 GPH!) GRAVITY FLAW(Check all that apply): E38. DAILY VISUAL MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARELY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all ILat apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ®a. AUTO PUMP SHUT OFF WHEN ALEAK OCCURS y❑�,AUTO PUMP SHUT OFF WHEN A LEAK OCCURS b.AUTO POMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ` \b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑c. NOAUTOPUMP SHUT OFF ❑c. NOAUTOPUMP SHUT OFF 011. AUTOMATICLINE LEAK DETECTOR(3.0 GPH TEST)W1 HFLOWSHUT OFF OR RESTRICTION !i. AUTOMATIC LEAK DETECTOR 012. ANNUAL INTEGRITY TEST(0.1 GPB) [112. ANNUAL INTEGIUTYTEST(0.1 GPH) SUCTTON/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Cheek all that apply) ❑14. CONTINUOUS SOME SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITHM AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LANE LEAK DETECTOR (3.0 GPH TESL) WITHOUT FLOW ❑l5. 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 GPIs) [117. DAILY VISUAL CHECK ❑17.DAILY VISUAL CHECK VILL DISPENSER CONTAINMENT DISPENSER CONTAINMENT a6S. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04. DAILY VISUAL CHECK 469. DATE INSTALLED 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCHU NER MONITORING 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR U - DISPENSER+AUDIBLE AND VISUAL ALARMS [16. NONE 'fw DL OWNER/OPERATOR SIGNATURE I ceRify that the information provided herein is hue and accurate to the best of my knowledge. SIGNATUREOFOWNER/OPERATOR Ca DATE: .- j-d 470. I NAME OF OWNER/OPERATOR 6mint): C D TlIkE OFO O^'{r1�AC�V*- OWNER/OPERATOR- C r F .\%-NF Permit Nimber(Agency use only) 473. Permit Approved By(Ageucynsewl y) 474. 1 Permit Expiration Dare(Agucy=only) 475.