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( 1 ,LK166 <br /> UNIF D PR RAM CO20NSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 1� C <br /> VI.PIPING.CONSTRU�CTION Checked Ih4t I .: _ _ Pae of <br /> UNDERGROUND PIPING <br /> SYSTEMTYPE O1,,R SUpE ABOVEGROUND PIPING <br /> .SUCTION ❑3.GRAVITY 438. ❑1.PRESSURE <br /> MAN FACTURER D 1.SINGLE WALL 0 3.LINED TRENCH 0 99.OTHER q6p, 2.SUCTION ❑3.GRAVITY 459 <br /> ❑2.DOUBLE WALL LJ I.SINGLE WALL 0 95.UNKNOWN 462 <br /> IMKNOWN D 2.DOUBLE WALL <br /> MANUFACTURER 0 99.OTHER <br /> ARE STEEL 461. MANUFACTURER <br /> ❑6.FRP COMPATIBLE W/10o%METHANOL ❑1.BARE STEEL 463. <br /> 0 2,STAINLESS STEEL 0 7.GALVANIZED STEEL ❑6.FRP COMPATIBLE W/100%METHANOL <br /> 0 3.PLASTIC COMPATIBLE WITH CONTENTS 2.STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 04.FIBERGLASS 095,UNKNOWN 03.PLASTIC COMPATIBLE W/CONTENTS <br /> 0 8.FLEXIBLE(HDPE) 0 99.OTHER C3 e.FLEXIBLE(HDPE) ❑99.OTHER <br /> ❑4.FIBERGLASS <br /> ❑5.STEEL W/COATING El 9.CATHODIC PROTECTION 0 9.CATHODIC PROTECTION <br /> 444 ❑S STEEL W/COATING 0 95.UNKNOWN <br /> "VII.PIP-YNf4`,UNU PID$TEGTION dA .1r,zi I - . 465. <br /> UNDERGROUND PIPING. Atpbi non ahheanbnironn ro ram shill' subm rtedt/rig a44gp u¢ <br /> SINGLE WALL PIPING ABovnUKUUND PIPING <br /> PRESSURIZED PIPING(Check all that a 1 466. SINGLE WALL PIPING <br /> apply): 461. <br /> 0 1. ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WLied AUTO PUMP PRESSURIZED PIPING(Check all that apply): <br /> AND SYSTEM DISCONNEC <br /> SHUT-OFF FOR LEAK,SYSTEM FAILURE - 01. ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> +AUDIBLE AND VIS UAL ALARMS, , TION SRUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> 0 2. MONTHLY 0.2 GPI TEST <br /> +AUDIBLE AND VISUAL ALARMS, <br /> 02. MONTHLY 0.2 GPH TEST <br /> ❑3. ANNUAL INTEGRITY TEST(0.I GPH) //n <br /> ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [34. DAILY VISUAL CHECK <br /> CONVENTIONAL-SUCTION SYSTEMS <br /> ❑ TRIENNIAL PIPING CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> S. DAILY VISUAL MONITORING OF PUMPING SYSTEM+T <br /> INTEGRITY TEST(0.1 GPH) 05. DAILY VISUAL MONITORING OF PIPING ANDPUMPINGSYSTEM <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> 07. SELF MONrrORING 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> CRAVI7'y FLOW <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> 07. SELFMONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> GRAVITY FLOW(Check all that apply): <br /> 08. DAILY VISUAL MONITORING <br /> SECONDARILY CONTAINED PIPING <br /> ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH)PRESSURIZED PIPING(Check all that apply): SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL I0. <br /> ALARMS AND(Check TURBINE <br /> one) CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> 0 e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ALARMS AND(Check one) <br /> 0 It.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM On AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> DISCONNECTION 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> 00. NO AUTO PUMP SHUT OFF DISCONNECTION <br /> 0 11. AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT Oc. NO AUTO PUMP SHUT OFF <br /> OFF OR RESTRICTION 0 11.AUTOMATIC LEAK DETECTOR <br /> 0 12. ANNUAL INTEGRITY TEST(0.1 GPH) 0 12.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM <br /> SUCTIONIGRAVITY SYSTEM <br /> [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Cheek all that apply) EMERGENCY GENERATORS ONLY(Check ell that apply) <br /> 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF. 014. CONTINUOUS SUMP I aF Y) <br /> AUDIBLE AND VISUAL ALARMS WITHOUT AUTO PUMP SHUT OFF <br /> 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WW FT TOUT FLOW AUDIBLE AND VISUAL ALARMS <br /> SHUT OFF OR RESTRICTION D 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> 016. ANNUAL INTEGRITY TEST(0,1 GPH) ❑16- ANNUAL INTEGRITY TEST(0.1 GPH) <br /> ❑17. DAILY VISUAL CHECK " 017. DAILY VISUAL CHECK <br /> dTfIiNSEfiir.O£.-'Al'NtF,4N„T,: <br /> DISPENSER CONTAINMENT 468. 01. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE <br /> DATE INSTALLED 0 4. DAILY VISUAL CHECK 469. <br /> ❑2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCWLMER MONITORING <br /> 03. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR <br /> DISPENSER AUDIBLE AND VISUAL ALARMS 06. NONE <br /> IiX bl3%Nk1?tOP1eRk0143TGi9A'ACIIi <br /> INAMEOF <br /> e informa' n provided herein is true and accurate to the best of my knowledge. <br /> PERATOR DATE: <br /> RATOR(pTITLE OF OWNER/OP RATOA epcy use only) 471. Petndl proved B A enc use only) <br /> Y( e Y Y) 474. Pemtit Ezpiratian Date(Agency use only) 473. <br /> UPCF hwfwrc-b(1/99)-3/4 http://w y.unidocs.olg <br /> Rev.02/16/00 <br />