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OIFIED PROGRAM CONSOLIDATED OMSITE C,2 705449/05449PIPING UNDERGROUND STORAGE TANKS - TANK PAGE 5 iyL�w VL PIPING CONSTRLCTION(cheekal/matapply) Page _ of AROVEGROUND PIPING SYSTEM TYPE ,PRESSURE E12.SUCTION [13.GRAVITY 458 ❑1.PRESSURE 02.SUCTION ❑3.GRAVITY 459 CONSTRUCTION/ ❑1.SINGLE WALL El 3.LINED TRENCH [199.OTHER 460 E]1.SINGLE WALL [195.XERXES 462 W.MANUFACTURER DOUBLE WALL El95.XERXES E12.DOUBLE WALL E199.OTHER MANUFACTURER 461 MANUFACTURER 463 El 1.BARE STEEL 06.FRP COMPATIBLE W,i00w METHANOL ❑LBAAE STEEL ❑6.FEE COMPATIBLE W/100%METHANOL MATERIALS AND ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL CORROSION ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑95.XERXES ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑S.FLEXIBLE(HDPE) 099.OTHER PROTECTION .FIBERGLASS ❑8.FLEXIBLE(HDPE) E199.OTHER ❑4. FIBERGLASS 09.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464 ❑5. STEEL W/COATING ❑95. XERXES 465 VII.PIPING LEAK DETECTION(Check all that apply)(A description ofthe mannoring program shall be submitted to the local agaaey) SINGLE WALL PIPING SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Cheek all that apply): ❑ I. 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 ❑ 2. MONTHLY 0.2 GPH TEST ❑ 2. MONTHLY 0.2 GPH TBET ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3. ANNUAL C TEST(0A GPH) El 4. DAILY VISSUALUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check a4 that apply): CONVENTIONAL DAILY VISUAL TION ❑ 5. DAILY VISUALMONITORING OFPIPINGAND PUMPING SYSTEM ❑ 5 DAILY VISUAL MONITORING OF PUMPING EYSTEM+TRIENNIAL PIPING INTEGRITY TEST(0.1 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 SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check tall that apply). ❑ 9 BIENNIAL INTEGRITY TEST(0 I GPH) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0 I GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all,hat apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) (Check oae) ❑ o AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ Is. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION Is, AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ c. NO ACRO PUMP SHUT OFF DISCONNECTION ❑ 11, AUTOMATIC LEAK DETECTOR ❑ c. NO AUTO PUMP SHUT OFF ❑ 12. ANNUAL INTEGRITY TEST(0,1 GPH) I AUTOMATIC LIVE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTIONf n�'!''�Q SUCDON/GRAVITY SYSTEM: 12. ANNUAL INTEGRITY TEST(0.1 GPH) µ - EW I� 5. ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS SUCTION/GRAVITY SYSTEM: EMERGENCY GENERATORS ONLY(Checka//that apply) ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 14. CONTINUOUS SUMP SENSOR 3DIMU AUTO PUMP SHUTOFF+AUDIBLEANDVISUAL ALARMS ❑ I5 EMERGENCY GENERATORS ONLY(Cherkall that apply) . AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑ I4. CONTINUOUSSUMPSENSORWITHO AUTO PUMP SHUT OFP+pIIDIBLH AND VISUAL ALMUAS 16, ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHO FLOW SHUT OFF OR ❑ 17. DALLY VISUAL CHECK RESTRICTION ❑ 16. ANNUAL MTEGRITY TEST(0.1 GPH) ❑ 17 DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED 466 ET2.CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LMR/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 6.NONE 469 IX.OWNER/OPERITOR SIGNATURE I certify that the information provided herein 1s we and accumtc to the but ofmy knowledge. EIG A RE OFO OPERATOR,P- DATE 470 13 2t�oa. NAME 0 R/OPERATO (prinq 471 TITLE OF OWN OPERATOR 472 JANETTE M.THOMPSON FOR CIRCLE K STORES,INC. COMPLIANCE SPECIALIST Permit Number(For local use any) 473 Pend:Approved(Forlocal use only) 474 Pemdt Eepbstim.Date(For local use only)475