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�IFIED PROGRAM CONSOLIDATED FOR TANK: TA0505680 PR#: PR0231227 FAC#: FA0004033 UNDERGROUND STORAGE TANKS - TANK PAGE 2 12,1131o) vtV1.PIPING CONSTRUCTION(ChFk.11 dlm.pph,) P sen DNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 91PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 45e ❑ I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 4W ❑ 1.SINGLE WALL ❑ 95.UNKNOWN 063 ®2.DOUBLE WALL 095.UNKNOWNEl2.DOUBLE WALL C1 ",OTHER 463 461 MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑6.FRP COMPATIBLE w/IW..WTHANOL ❑ 1.BARE STEEL [-16,FRP COMPATIBLE n/IOU"/.METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL F1 PLASTIC COMPATIBLEW/CONTENTS [:] 95.UNKNOWN F] PLASTIC COMPATIBLE W/CONTENTS El 95.UNKNOWN M 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ W.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 VI.PIPING LEAK DETECTION(clack all wt apph)(A,on,,,,nier.fiken atirmnig,ro,arn shall x submklai o ma lecal agency.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check ell that apply): PRESSURIZED PIPING(Check all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR) ,,SYSAL TEM FAILURE,AND SYSTEM DISCONNECTION'AUDIBLE AND VISUAL 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(Check all that apply) CONVENTIONAL SUCTION SYSTEMS ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH ❑ e.DAILY VISUAL MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(clackaa) ALARMS AND(Cluck one) ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM M b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ® 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/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 thin-111) EMERGENCY GENERATORS ONLY(C krill metapph) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF• ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW E] I5.AUTOMATIC LINE LEAK DETECTOR Ci 0 GPH TEST)WITHOUT FLOW ❑ SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ® 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ® I.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 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 WITH AUTO SHUT OFF FOR ❑ 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS LY.OWNER/OPERATOR SIGNATURE i emtifv IM10w Inforeancepravided hmin is we and accumm Ia dm ben pinry kno,Hedge. 470 SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNER/OPERATOR(print) 411 TITLE OF OWNER/OPERATOR 473 JANETTE M THOMPSON COMPLIANCE SPECIALIST Pemdt Numen(For legal use only) 473 ft.r A,.,a (For lochia.only) 474 Pamh E�pwtian D.te(Fmleeal mconlc) 475 PT0013192 UPCF(12/99 revised)