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Oka 1611 UNIFIEU,tEgiRRAM CONSOLIDATED FORM TANKS Oti, UNDERGROUND STORAGE TANKS -TANK 2 Pa VI:PIPING CONSTRUCTION Ch«tan th,r ''i e pf UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑1.PRESSURE .SUCTION 0 3.GRAVITY 458. 0 1.PRESSURE 0 2.SUCTION CONSTRUCTION/ D 1.SNGLE WALL D 3.GRAVITY 459. MANUFACTURER ❑�/3.LVED TRENCH 0 99.OTHER 460. D-1.SINGLE WALL 0 95.UNKNOWN 462. 02.DOUBLE WALL �Fa,UNKNOWN D 2.DOUBLE WALL 0 99.OTHER MANUFACTURER 461. MANUFACTURER 463, ARE STEEL ❑6.FRP COMPATIBLE W/I00°/.METHANOL ❑1.BARE STEEL ❑6.FRP COMPATIBLE W1100%METHANOL 0 2.STAINLESS STEEL D 7.GALVANIZED STEEL 0 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 3.PLASTIC COMPATIBLE WITH CONTENTS ❑93.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) ❑99.OTHER 0 4.FIBERGLASS 0 S.FLEXIBLE(HOPE) 1199.OTHER D 4.FIBERGLASS 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION ❑9 CATHODIC PROTECTION 464 ❑5.STEEL W/COATING ❑95.UNKNOWN 65. VIUNDERGGLEA PIPING TION Ch«k ellthar 1 -,Aderfi Fano[IAcinen iann oram'ewl be.eubraHMtothemc.la UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PD'ING ass. SINGLE WALL PIPING PRESSURIZED PIPING(Check all that apply); 467. PRESSURIZED PIPING(Check all that apply): C3 I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP D 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. 0 2. MONTHLY 0.2 GPH TEST / 02. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST(0.1 GPH) (//J-f_// /(/ 03. ANNUAL INTEGRITY TEST(0.I GPH) •,(/7 ❑4. DAILY VISUAL CHECK CONVENTIONAL VISUAL NTORINGS CONVENTIONAL SUCTION SYSTEMS(Check all that. I ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING PF Y) INTEGRITY TEST(0.1 GPH) 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) 07. SELFMONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW D7. SELF MONITORING 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): 08. DAILY VISUAL MONITORING 09. 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(Check one) ALAo 0 ARMS AND(Check m) L AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 AUTO PUMP SHIT OFF WHEN A LEAK OCCURS DIS El b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Oc. NO AUTO PUMP SHUT OFF Oc. NO AUTO PUMP SHUT OFF D 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION 0 11.AUTOMATIC LEAK DETECTOR D 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM D 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 014. CONTINUOUS SUMP SENSOR WIW�AUTO PUMP SHUT OFF. 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW SHUT OFF OR RESTRICTION [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) 0 16. ANNUAL INTEGRITY TEST(0.1 GPH) [116. ANNUAL INTEGRITY TEST(0.1 GPH) 0 17. DAILY VISUAL CHECK [317, DAILY VISUAL CHECK VAL"PISPENSER CONTAINAENT DISPENSER CONTAINMENT 469, D1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE _.04. DAILY VISUAL CHECK 469. DATE INSTALLED 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D5. TRENCH/LINER MONITORING D 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS 06. NONE LY.OWNER/OPERATOR SIGNATURE' Icertifyth vided herein is trueand accurate to the best ofmy knowledge. OR DATE: / 470, rint): --� TITLEOFOWNER/OP RATOR: 472an. Permit proved By(Agency use only) 474. Per Expiration Date(Agency use only) S 475. UPCF hwfwrc-b(1/99)-3/4 http://"w.unidocs.org Rev.02/16/00