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�IFIED PROGRAM CONSOLIDATED FOR* TANK: TA0504845 PR#: PR0231482 FAX#: FA0000720 UNDERGROUND STORAGE TANKS -TANK PAGE 2 11) .q VI.PIPING CONSTRUCTION(Chink all mat apply) Poga s UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ I.PRESSURE 7E 2.SUCTION ❑3.GRAVITY 458 ❑ LPRESSURE [-12.SUCTION [-13.GRAVITY 4 CONSTR=014 ❑I.SINGLE WALL ❑3.LINED TRENCH ❑".OTHER 460 [1 1.SINGLE WALL El 95.UNKNOWN 462 *DOUBLE WALL ❑95.UNKNOWN ❑ 2.DOUBLE WALL ❑ 99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/100%METHANOL ❑ 1.BARE STEEL ❑ 6.FRP COMPATIBLE w/1 W%METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER [14.FIBERGLASS ❑8.FLEXIBLE(HDPE) ❑ 99.OTHER �KS.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ S.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 VII.PIPING LEAK DETECTION(aak all that apply)(A&caption orma amamrinipro a chap he sulaunealomeleca1 rein Y.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS. VISUAL ALARMS. ❑ 2.MONTHLY 0.2 GPH TEST ❑ 2.MONTHLY 0.2 GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPH) ❑4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ e.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 SUMP SENSOR WITH AUDIBLE AND VISUAL 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Cheek one) ALARMS AND(Chxk 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 ❑h.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c.NO AUTO PUMP SHUT OFF ❑c.NO AUTO PUMP SHUT OFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11,AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 1913.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(C all man apply) EMERGENCY GENERATORS ONLY(Clack,all fat appy) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF e ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPIU ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT F1 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATEINSTALLLLjED 468 r�2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ` ❑`3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 DC.OWNERIOPERATOR SIGNATURE t if, tmeinfo.ion v�o.iaeameia ie Sana aeemam to merest Oran lmawlplge. SI TU FO E ERATOR DATE no S•1Z-bS N OF WNER/OPERATOR(paiat) 4n TITLE OF OWNER/OPERATOR _ az PcactNumber(Forloaalmeoey) 473 Permit AMmvea(Fm local use GAY) 474 Permit Expiration Date(F.,local use only) 475 PT0000724 EE0003804 6/30/2003 UPCF(12/99 revised)