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} i i <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br /> V L PIPLYG CONSTRUCTION(a ck av m'r,rl) <br /> UNDERGROUN PIPING ABOVEGROUND P ING <br /> SYSTEM TYPE []].PRESSURE 2.SUCTION 3.GRAVITY 458. ❑1.PRESSURE 2.SUCTION 3.GRAVITY 459, <br /> CONSTRUCItOryMANUFACTURER D 1.SINGLE WALL D 3.LINED TRENCH ❑go.OTHER 460. 1,SINGLE WALL <br /> D2.DOUBLE WALL [3 95.UNKNOWN 46z. <br /> ❑95.UNKNOWN �2.DOUBLE WALL <br /> ❑99.OTHER <br /> MANUFACTURER 461, MANUFACTURER <br /> 40 <br /> 1.BARE STEEL <br /> [16.FRP COMPATIBLE W/100°/"METHANOL ❑1.HARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL <br /> [12.STAINLESS STEEL [17.GALVANIZED STEEL [12.STAINLESS STEEL D 7.GALVANIZED STEEL <br /> D 3.PLASTIC COMPATIBLE WITH CONTENTS 1195.UNKNOWN D 3.PLASTIC COMPATIBLE W/CONTENTS D S.FLEXIBLE(HOPE) [199.OTHER <br /> D 4.FIBERGLASS D S.FLEXIBLE(HOPE) Cl 99.OTHER [14.FIBERGLASS D 9.CATHODIC PROTECTION <br /> ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 461, D 5.STEEL W/COATING D 95.UNKNOWN <br /> VIL PIPING LE AKDETECTION(ch:ctau mei I (a deacri oon aflhe rmnitorin m nehall tie'wtmntea waa Wa <br /> SINGLE WALL PIPING i a ass. <br /> UNDERGROUND PIPING /•V/� ABOVEGROUND PIPING 466. SINGLE WALL PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 467 <br /> D L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAIL <br /> +AUDIBLE AND VISUAL ALARMS. +pUDBLE AND VISUAL ALARMS. URE,AND SYSTEM DISCONNECTION <br /> E12. MONTHLY 0.2 GPH TEST 112 MONTHLY 0.2 GPH TEST <br /> [33- ANNUAL INTEGRITY TEST(OU GPH) D 3. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [14. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> E15 DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING <br /> INTEGRITY TEST(0.1 GPH) [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND P@ING): 06. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> 07. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITYFLOW D7. SELF MONITORING <br /> 139 BIENNIAL INTEGRITY TEST(O.1 GPH) GRAVITY FLOW(Check all that apply): <br /> D 8. DAILY VISUAL MONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check ah that apply): <br /> PP Y): <br /> 10. CONTTURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. <br /> ALARMSMS AND(Check one) CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> AND ALARMS AND(Check once) <br /> D a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM D b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Dc. NO AUTO PUMP SHUT OFF Dc. NO AUTO PUMP SHUT OFF <br /> ❑I1. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHOT <br /> OFF OR RESTRICTION D l L AUTOMATIC LEAK DETECTOR <br /> D 12. ANNUAL INTEGRITY TEST(0.1 GPH) D 12.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS D 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> [314. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF D 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 015. SHUT OFF OR RESTRICTION DETECTOR (3.0 GPH TEST) WITHOUT FLOW D 15 AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> D 16. ANNUAL INTEGRITY TEST(0.1 GPH) D 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [117, DAILY VISUAL CHECK <br /> [117.DAII,Y VISUAL CHECK <br /> VID..DISPENSEl2 CONTAINMENT <br /> DISPENSER CONTAINMENT 468. D L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE D 4. DAILY VISUAL CHECK 469. <br /> DATEINSTALLED D2. CONTINUOUS DISPENSER PAN SENSORAUDIBLE AND VISUAL ALARMS D5. TRENCH/LINER MONITORING <br /> D3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR <br /> D LSPEIYSER+AUDIBLE AND VISUAL ALAILMS . NONE <br /> LY.OWNER/OPERATOR SIGNATURE <br /> I certify that the htformation provided herein is true and accurate to the best of my knowledge. <br /> SIGNA WNER/OP T DATE: <br /> 470. <br /> NAME OF OWNER/OPE T (prpV): TITLEOFOWNER/OPERATOR: z. <br /> a 9 <br /> Permit Number(Agency use only) qn. Permit Approved By(Agency use only) 474. 1 Permit Ex 'anion Date(Agency use oNy) 475, <br /> UPCF hwfwrc-b(1/99)-3/4 littp://www.nnidoes.org <br /> Rev.02/16/00 <br />