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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 X!d::PI�' �COHSI'ItU Pae of UNDERGROUND PIPING L�tett(tll;tlur I SYS2EMTYPE ❑t.PRESSURE ABOVEGROUND PIPING CONSTRUCTION/ 2•SUCTION ❑3.GRAVITY 4sa. ❑ 1.PRESSURE 2.SUCTION MANUFACTURER ❑I.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460 ❑3 GRAVITY 459. ❑2.DOUBLE WALL 01.SINGLE WALL ❑95.UNKNOWN 462 ❑95.UNKNOWN ❑2.DOUBLE WALL MANUFACTURER ❑99.OTHER I.BARE STEEL 461. MANUFACTURER ❑6.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL 46I. ❑2.STAINLESS STEEL [:17.GALVANIZED STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑3.PLASTIC COMPATIBLE WITH CONTENTS ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE HDPE ❑4.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑99.OTHER (HOPE) ❑99.OTHER ❑5.STEEL W/COATING ❑4•FIBERGLASS ❑9.CATHODIC PROTECTION ❑9.CATHODIC PROTECTION 464. ❑S.STEEL W/COATING V11.1- IN.1,;)�AIE,DETI? ❑95.UNKNOWN 465. �'ir{IOI <Sltetik:alf th4a 1 Adescri tion oCthe,nnnitorin ro YaMt WI W submitted to thcbcal cnc. UNDERGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING ABOVEGROUND PIPING PRESSURIZED PIPING(Check all that apply):pp y)' 467 C3 I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP PRESSURIZED PIPING(Check all that apply): SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION ❑1. ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP +AUDIBLE AND VISUAL ALARMS. SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION C)2. MONTHLY 0.2 GPH TEST +AUDIBLE AND VISUAL ALARMS.❑3. ANNUAL INTEGRITY TEST(0.1 GPH) // [:12. MONTHLY 0.2 GPH TEST N� ❑3. ANNUAL INTEGRITY TEST(0.l GPH) El 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMSEl SUCTION SYSTEMS(Check all that a ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING apply) INTEGRITY TEST(0.1 GPH) [35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [:16. TRIENNIAL INTEGRITY TEST(0.1 GPH) ❑7. SELF MONITORING GRAVITY FLOW SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑8. 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 SUhiP SENSOR WITH AUDIBLE AND VISUAL l0. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check 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 ❑b. AUTO PUP SHUT OFF FOR LEAKS, DISCONNECTION DISCONNECTION. SYSTEM FAILURE AND SYSTEM ❑c. NO AUTO PUMP SHUTOFF ❑c. NO AUTO PUMP SHUT OFF ❑11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION ❑11.AUTOMATIC LEAK DETECTOR ❑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 that apply) EMERGENCY GENERATORS ONLY(Check all that apply) ❑14. CONTINUOUS SUMP SENSOR WIC AUTO PUMP SHUT OFFT P ❑I4. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR ( n3.0 GPH TES W U FLOW AUDIBLE AND VISUAL ALARMS SHUT OFF OR RESTRICTION ❑15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK ❑17. DAILY VISUAL CHECK YTIL•� ��SL•Ri�!(� A�NJi': DISPENSER CONTAINMENT 46a. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE E-14. DAILY VISUAL CHECK 469. DATE INSTALLED E12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING ��k�r �1 J ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ,;/ DISPENSER+AUDIBLE AND VISUAL ALARMS _IiC NONE -777 I certify that the information provided herein-is&4e_)tnd acc ate to the best of my knowledge. SIGNATUREOFOWNMO,PERATO _ DATE: /-- - r� J 470 NAME OFOWNER/OPERATOR(pritttJ� TITLE OF OWNELZZ OPERATO 472. Permit Number(Agency use only) 473. Permit Approved By(Agency use only) 474. Permit Expiration Date(Agency use only) 475. UPCF hwfwrc-b(1/99)-3/4 http://www.unidocs.org Rev.02/16/00