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It 0 <br /> 4 UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 <br /> VI.PIPING CONSTRUCTION Check all that a I I Page_of_ <br /> UNDERGROUND PIPING I ABOVEGROUND PIPING <br /> SYSTEM TYPE D 1.PRESSURE 0 2.SUCTION 0 3.GRAVITY 458 1 O 1.PRESSURE D 2. SUCTION 0 3.GRAVITY 459 <br /> CONSTRUCTION D L SINGLE WALL 0 3.LINED TRENCH D 99 ER 460 0 1.SINGLE WALL O 95.UNKNOWN 40 <br /> MANUFACTURER 0 2.DOUBLE WALL D 95.UNKNOWN D 2.DOUBLE WALL 0 99.OTHER <br /> MANUFACTURER 461 I MANUFACTURER 463 <br /> 0 I.BARE STEEL [16.FRP COMPATIBLE w/100% METHANOL. 0 L.BARE STEEL 0 6.FRP COMPATIBLE W/IW%METHANOL <br /> 0 2.STAINLESS STEEL D 7.GALVANIZED STEEL 0 Unknown 0 2. STAINLESS STEEL 0 7.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE W/CONTENTS D 99.Other [13. PLASTIC COMPATIBLE W/CONTENTS D 8.FLEXIBLE(HDPE) D 99. OTHER <br /> 0 4.FIBERGLASS 0 8.FLEXIBLE(HDPE) 0 4. FIBERGLASS 0 9.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464 0 5. STEEL W/COATING 0 95.UNKNOWN 465 <br /> VIL PIPING LEAK DETECTION(a kali Mata I) Adexti tion of Ne moNtorin shell besubmitkdbahe loula <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING((heck all that apply): PRESSURIZED PIPING(Chcok all Owapply): <br /> O 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITFI AUTO PUMP SHUT ❑ I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+ <br /> AUDIBLE AND VISUAL ALARMS. AUDIBLE AND VISUAL ALARMS. <br /> 0 2.MONTHLY 0.2 GPH TEST ❑2. MONTHLY 0.2 GPH TEST <br /> 0 3.ANNUAL INTEGRITY TEST(O.IGPH) ❑3.ANNUAL INTEGRITY TEST((EIGPH) <br /> [14. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all No apply) <br /> 0 S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING <br /> INTEGRITY TEST(0.1 GPH) D 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): 0 6. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> [17.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELF MONITORING <br /> 0 9.BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all Wtapply): <br /> 0 8. DAILY VISUAL MONITORING <br /> 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check 910u apply): PRESSURIZED PIPING(Ch«k all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Ch«k one) ALARMS AND(Checkone) <br /> Oa. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM O b AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Oc. NO AUTO PUMP SHUT OFF Oc NO AUTO PUMP SHUT OFF <br /> 0 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT D 11 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> 0 12._ANNUAL INTEGRITY TEST(0.1 GPH) 0 12. ANNUAL INTEGRITY TEST(ol GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVTTY SYSTEM <br /> 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(aaokall wt apply) EMERGENCY GENERATORS ONLY(Check all Out apply) <br /> 0 14. CONTINUOUS SUMP SENSOR WITHOl1T AUTO PUMP SHUT OFF• 0 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW <br /> SHUT OFF OR RESTRICTION 0 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) O 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> D 17. DAILY VISUAL CHECK D 17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 01.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04.DAILY VISUAL CHECK <br /> DATEINSTALLED 4611 O2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05.TRENCH LINER/MONITORING <br /> 0 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS ❑6.NONE 469 <br /> IX.OWNERIOPERATOR SIGNATURE <br /> 10 fy Jut the inlomntion provided hmin to we and=c VaLe to Ne bafl ofay knowledge. <br /> SIGNATURE OF OWNER/OPERATOR - DATE 470 <br /> NAME OF OWNER/OPRATOR(print) OI 1 TITLE OF OWNER/OPERATOR Aln <br /> Fannon Nuaber(For local ase only) 473 Permit Appnoved(For local use only) 474 Panama Expiation Date,(For local use only) 475 <br /> UPCF(12/99 revised) 12 Formerly SVrRCB Forth B <br />