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f &IIFIED PROGRAM CONSOLIDATED SITE#2705449/05449 UNDERGROUND STORAGE TANKS - TANK PAGE 2 PIPING fi ( VI.PIPING CONSTRL CTION(Check all that apply) Page _ of UNDERGROUND PIPING ABOVEGROUND-PIPING SYSTEM TYPE RESSURE ❑2.SUCTION ❑3.GRAVITY 458 ❑1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 459 El 1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑L SINGLE WALL 95.XERXES CONSTRUCTION/ DOUBLE WALL ❑95.XERXES ❑ 462 MANUFACTURER ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑LBARE STEEL ❑6.FRP COMPATIBLE aril.METHANOL ❑LBARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL CORROSION 03.PLASTIC COMPATIBLE WITH CONTENTS ❑95.XERXES ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑7 GALVANIZED FLEXIBLE (HOPE)EL PROTECTION .FIBERGLASS 08.FLEXIBLE(HDPE) ❑99.OTHER ❑4. FIBERGLASS ❑9.FLEXIBLE((HOPE) ❑99.OTHER ❑5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑9.CATHODIC PROTECTION 095. XERXES 465 VII.PIPING LEAK DETECTION(chackarl that apply)(A description ojthe monitoring program shall be subminad to the local ngenry/ UNDERGROUND PIPING AROVRGROI IND PIPING SINGLE WALL PIPING SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that pply): ❑ 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 E] 2. MONTHLY 0.2 GPH TEST -12. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPH) El 3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 4, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Chttk all that apply): ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILYVISUALMONITORINGOFPIPINGANDPUApMG SYSTEM TEST F)I GPH) ❑ 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING) ❑ 7 SELFMONITORING ❑ 7. SELFMONI'TORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑ 9 BIENNIAL INTEGRITY TEST(0 1 GPH) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(O.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Chack all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10, CONTINUOUS TURBINE SUMP SENSOR VMW AUDIBLE AND VISUAL ALARMS AND(check ona) (Check ono) ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHAT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION �ixb AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ c. NO AUTO PUMP SHUT OFF DISCONNECTION ❑ 11. AUTOMATICLEAKDETECTOR ❑ c. NO AUTO PUMP SHUT OFF ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION p SUCTION/GRAVITY SYSTEM. 12. ANNUAL INTEGRITY TEST(0 I GPH) - P.IEW 96(Q5• ❑ 13. CONTINUOUS SUMP SENSOR,AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM: EMERGENCY GENERATORS ONLY(Check all that apply) ❑ 13. CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS ❑ 14. CONTINUOUS SUMP SENSOR}Yjg(QIL'T AUTO PUMP SHUT Off+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Chackal/that app/y) ❑ I5. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ 14. CONTINUOUS SUMP SENSOR WI.Tl#O AUTO PUMP SHUT OFF+AUDD3LE AND VISUALALARM$ ❑ 15. AUTOMATIC LINE LEAK DETECTOR 3.0 GPH TES 16. ANNUAL INTEGRITY TEST(0.1 GPH) ( T)WjT/i_QIL FLOW SHUT OFF 00. ❑ 17. DAILY VISUAL CHECK RESTRICTION ❑ 16. ANNUAL INTEGRITY TEST F)I GPH) ❑ V DAILYVISUALCHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT I FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILYVISUALCHECK DATE INSTALLED 468 Lj 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 ❑ 6.NONE 469 IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein u hue and accurate to the beat of my knowledge. SIGITANRE OF WOPERATOR DATE ji 13 a�2-- 470 NAME O WNER/OPERAT R(print) 471 TITLE OF OWNE PERATOR 472 JANETTE M.THOMPSON FOR CIRCLE K STORES,INC. COMPLIANCE SPECIALIST Permit Numbcr(For local we only) 473 Perrot Approved(For local we only) 474 Perrot Expiration Data(For lomd we only)475