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06/01/2007 22:54 12099549092 ALL INJURY CLINI(;JG PAGE 09/09 <br /> UN1aFiED pROGRANI SPL iDATED FORM <br /> M TANKS <br /> UNDERGROUND STOMA k E TANKS -TANIK PAGE 2 TM <br /> PYP T! <br /> psoVP,)RPUNA PIPING^ e� <br /> I ,,INDBROROUNDPIPING 3.GAAVt1Y I PRESSURE ❑�. 6uCT[ON d3.ORAYITY <br /> sYSreM TYPE ).PRWURE G L SUCTION ❑95.LMiCNOW N <br /> .ct <br /> ❑1.SINGLE WALL p!!.OTHER <br /> tINEDTRENC'.7I p9P'DTHFA DOUBLE WALL <br /> coh,,muc"ON 01.31NOUWALL 3. qI <br /> McNUFACI�ROL <br /> j&,DOUBLE WALL uPs.UNKNOWN '.1 MANUFACfURRR <br /> bIASRJFACITUREtL 6.FRP COMPAn SLE whN!AMSTBA <br /> ].HARE 8T8E4 ❑G.FRP COMPA7)DFR /TcmA 'ABTHANOL OI.BA t 5�1'�L TtIRL Q7,OALYANIIED STEEL <br /> a.STAINLESS STWL ❑7.OALVAN)Z�STILL Q Uft"O Q L TLC[OMPATI815 W'CDNTEN'f8 CI R FLEXIBLE(HIaPE) ❑�.GT R <br /> []%9. ,a,x ❑1. ❑9.CATNOD)c PROTP.CIION <br /> ❑S.PLASrCcOMPATIBLF WICOMBNTb �a. si® GLASS <br /> 044.PIBSROLASS 0 S.FLEMBLISQMPe) 1',f PS,S1NKNOWN <br /> GIS.STEEL WIMATINO Q 9.CATROOIC pgpT7ICTION 4N Q S. 8 L W/C.GAT]NO ti w Adl <br /> VIL FIN AM C ml4a wN GROf)ND ING <br /> U UR e[6 SfftOL6 WAY. <br /> L PIPTNC Ml <br /> SINCLE WALL PIPING PRFSNRI2EO PIPING(L .Il wwwdYT' AUTO PUMP <br /> DRBSSURIZED PIPING t(a[rArll ffi°PPL'% AUTO PUMPaNUT i CI L SLEGTRONIC LINK LEAK DETECTOR 3.0 OPN TEST SIN <br /> E3,,SLECTRONIC LINT tEAKDST>rR 3.0 OPFi TEST 1 SALT OFF fox LEAK SYSTlA1 PNLVRE AND 8Y37ES1 DtSOONNF-�t7�' <br /> OFF FOR LEAK,SYSTEM FNLtWF AND SYSTEM DICONN=M ,AUDIBLE AND VISUAL ALARMS <br /> AUf"LE AND VISUAL ALARMS. 1 ❑L MONTHLY 0.7 GPR TEST <br /> 0 x wOMFaS'0.1 CPF/TkTP Q 7.ANNUAL ITrGRITY TEST(0.LUPN) <br /> {]a..ANNUAL INTEGRITYTEITT IO.I Gm) p4. DAILY VISUAL=K <br /> CONVENTIONAL SUCTION SYSTOMS(CFMi W na4PPet) <br /> CON'VEN'TIONAL SUCTION STSTEMS +TRIENNIAL PIPING <br /> 0 S.DAIUY VISUAL MONRORING OF PUMaTZC+S�TEM []5, DAILY VISUAL NIOI'RTORiNo OF PIPING PND p(R.MNO$YS <br /> apTTy HIST{0.1 GPM) IMIX)RITV TEST(0-1 Op") <br /> SAFE SWOON 8Y9(2MS O40 VALVEs,N BELOW ORDUNOPIPINUk I ��SUCITON Y51LPA7.4(NO VALVu IN BELOW GROLMD PIPING): <br /> Q 7.SSLF MONTIOKINO Q 7. SELF MOMTCIUNG <br /> OFAVITT FLOW I Lo <br /> VITY ROW tioiii* Puaa aoeleY <br /> n 9.BIENNIAL 1N1'EOR7N'TEST(0.i OPI� I <br /> 1AILY VLIUAI.MONTTOR)NG <br /> IENNIAL INTEgItTYY T'PST(0.3 OEN7 <br /> SItCOe4DARILY CONTAINED PIPINGCONTnIF18D rIRINCURJ2RD lIPINO(C Olil l•lwaPiM) A)IDVISUAL <br /> PRESSURTLBDPIPING(ch.0 a aw-MY] NUOUS TURBINE BUM?SEN90RwwTN10CONTtNUOUSTURBIhYi BUMP SKNSOA Ym11 AUDIBLEVISUAL LARM AT.ID fChtd am)ALARMSAND{grskane) f t ALIO P(MiP S&''T OFF WHEN A 4XAA OCCURSAND 9YSTaL'+A AUTO Rw S)/VT OFF WHEN A LEAK OCCURS D AlJTO PUMP Sao OFF FOR LEAKS.SvSTENL FAILUREAUTO PUMP SMUT OPF FORLFAKS,9YbTEM ENLURE ANO SYSTEM i DiBCONNECITONrnscoNx)scTlor o HPO AUZO PUMP SMUT OFF <br /> ❑a NO AUTO PVMP SMUF OFF flpW SNVT . AUTOMATIC L€AK DETECTOR <br /> 11. ON QR�TUR.II=OINDSTECTORIa.OOPNT697)WflEOIUTYTESTII,DPN). ANNUAL)NTE�12. ANMJALIPlIF.GRITYTEST(0.1C7H) G741OAAYITY SYSTEISl1CT1GNAIRAVUY SYSTPM . mNI1NU0U9 SUMPSENSOR+'AUp1H1.E AtvD e7IS. CONT[N000E SUMl SENSOR+AUDIBLE AND V]SUAL ALAN+(S E8IFIIOEInGY GSNEMTORS bnLY I OONTMUOUS SUMP SENSOR F�T_t10Si AUTO PUMP$HU[W PEMERGENCY GBNZATATORR ONLY M.Rxt eli NYmplr)14. CONTINUOUS SUMP SENSORAI1�AUTO PUMP aNVT OFF• AUDIBLE AND VISUAL ALARMSAUDIBLE ANO VISUAL Ay,AAMB TEST]WITN(XII FLOW . AUTOMAnC LINK LPAKPSTE6TaRfa o GPr TE3T1 <br /> 11 SXCTIrr OPT� �OtN1'ECTOR(a.o orE1 a ANNUALINPECRITY16.ANNUAL IXITEORITY TEST(o.t G7. DAILY VISUAL CII; <br /> [317. DAILY VISUALCIECK VIII.DTSPEN , R CONTAN INT <br /> CHECK <br /> Oils T I.FLDATMBCHANISMTHATSM760 <br /> FF S R VALVE ❑4.DA1Ll'VISUAL <br /> .e5 I <br /> - .CONTINUOUS D79PeNSER PAN SENSOR+ UDIBLBANDVISUAL PLARM9 ❑S.TRENCH LINER/IDN In <br /> DATE INSTALLED fUOUS DtSmmistt PAN SENSOR ANO SHUT OFF EOR �6.NONE <br /> Cl 9-Ds IlIL+ DIBLEAND 4U AL <br /> "A R SIGNATURE <br /> ( e)0 <br /> icdb ll^•Oc' ws wwi4N Laa ' wdw Fe4MwI vMMwP• DATEIONA ?7 <br /> � E P TOR <br /> NA OF OWN TOR r I b a^1 <br /> meJ Fwaw) e, Pemw AFP•e•P4lfvr, o•h) <br /> 4 04X91 Iprmion DJ.(Fer le=d uew ) <br /> wm,Nno4rt, i <br /> ),I Formerly 9 W RCB Form B <br /> L1PCF(12/99 revised) <br />