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{ WIFIED PROGRAM CONSOLIDATED IsmSITE#2705449/05449 gUr� PIPING UNDERGROUND STORAGE TANKS - TANK PAGE VI.PIPING CONSTRLCTION(eheakall ebmpply) Page of SYSTEM TYPE .PRESSURE 0 2.SUCTION ❑3.GRAVITY 458 ❑I.PRESSURE ❑ 1 SINGLE W 3.LINED TRENCH ALL ❑ [199.OTHER 460 ❑2.SUCTION E13.GRAVITY 459 CONSTRUCTION/ ❑95.XERXES ❑1.SINGLE WALL [195.XERXES 462 MANUFACTURER 2.DOUBLE WALL E:12.DOUBLE WALL [199.OTHER MANUFACTURER 461 MANUFACTURER 463 Eli BARE STEEL 06.FRP COMPATIBLE you.METHANOL [It.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL MATERIALS AND ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL 07.GALVANIZED STEEL CORROSION ❑3. LASTIC COMPATIBLE WITH CONTENTS 095.XERXES ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑8.FLEXIBLE(HDPE) 099.OTHER PROTECTION IT5KZIBERGLASS 08.FLEXIBLE(HDPE) E399.OTHER ❑4. FIBERGLASS ❑9.CATHODIC PROTECTION 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95. XERXES 465 VII.PIPING LEAK DETECTION(cheak an that apply)(A deerriptice ojthe tnoniroring pWgrom shall besubmitted to the Iwai agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TESTMM AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST YM 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 ❑ 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: CONVENTIONAL SUCTION SYSTEMS(Chak all that apply): ❑ 5 DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST E)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. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Cheakall that apply): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPH) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIA.INTEGRITY TEST IDA GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Cheek all that app/y): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WIT F AUDIBLE AND VISUAL ALARMS AND(check one) (Check one) ❑ u. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ c. NO AUTO PUMP SHUT OFF DISCONNECTION ❑ 11. AUTOMATIC LEAK DETECTOR ❑ c. NO AUTO PUMP SHUT OFF ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPH) 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST))M FLOW SHUT OFF OR RESTRICTION '11 nn� SUCTION/GRAVITY SYSTEM: 12, ANNUAL INTEGRITY TEST in 1 GPH) - N�WI�I K4.S. ❑ 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 SENSORTH l�V SIL[AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check./l that apply) ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ 14. CONTINUOUS SUMP SENSOR SITTHOL AUTO PUMP SHUTOFF-AUDIBLE AND VISUAL ALARMS ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ I5. AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST)MT O FLOW SHUT OFF OR ❑ 17 DAILY VISUAL CHECK RESTRICTION ❑ 16 ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17 DAILYVISUALCHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE El 4.DAILY VISUAL CHECK DATE INSTALLED 468 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WI Ty AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6.NONE 469 IX.OWNER/OPERITOR SIGNATURE 1 certify that the infermation provided herein u we and accurate to the best afro,knowledge. SI A REOFO OPERATOR DATE ' .Au 470 NAMED WNER/OPERATOR ri®I 471 TITLEOFO OPERATOR 472 JANE VE M.THOMPSON FOR CIRCLE K STORES,INC. COMPLIANCE SPECIALIST Penin Number(For local use only) 473 Pmmt Approved(For local we only) 474 1 Pemdt Expiration Date(For local use a,,I,)475