BILLING - Laserfiche WebLink

Home Browse Search

�NIFIED PROGRAM CONSOLIDATED FORW/j. '{ TANK: TA0438303 u _ PR#: PRO234393 f,' FAC#: FA0003670 UNDERGROUND STORAGE TANKS - TANK PAGE 2 S J VI.PIPING CONSTRUCTION(LT kdl one vply) Peen of5 UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ I.PRESSURE 912.SUCTION ❑ 3.GRAVITY 458 ❑ LPRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL 03.LINED TRENCH ❑ 99.OTHER 469 ❑ I.SINGLE WALL ❑95.UNKNOWN 462 ❑2.DOUBLEWALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461 MANUFACTURER 463 ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE w/196%METHANOL ❑ I.BARE STEEL ❑ 6.FRP COMPATIBLE wl loo%METHANOL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑PLASTIC COMPATIBLE W/CONTENTS El 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS 095.UNKNOWN ®4.FIBERGLASS ❑ S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑99.OTHER ❑S.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 [:15.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 465 VD.PIPING LEAK DETECTION(Ch eiltwapPM(Adcm;nrian slwl becabmind mdmloal am,.) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ I.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 02 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+TRIENNEEAL PIPING [:15.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) ❑6.TRIENNIAL INTEGRITY TEST Al GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑ 7.SELF MONITORING GRAVITYFLOW ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPH GRAVITY FLOW(Check all that apply): ❑ S.DAILY VISUAL MONITORING ❑ 9.BIENNIA.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(Chakaro) ALARMSAND(Cb .) ❑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 PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑C.NO AUTO PUMP SENT OFF ❑ c.NO AUTO PUMP SHUT OFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ I I AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 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(C1¢ck ill flat appy) EMERGENCY GENERATORS ONLY(Cb kall that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF` ❑ 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 GPH) ❑ I6.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VRI,DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4.DAILY VISUAL CHECK DATE INSTALLED 468 ® 2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING E]3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR E]6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER/OPERATOR SIGNATURE 1 certify due the efnmation ptmdddhacin 4 mead amameto the bat ofmyk dge SIGNATURE OF OWNERIOPERATOR DATE 470 NAME OF OWNER/OPERATOR(print) TITLE OF OW NER/OPERATOR CHARLES BUSALOCCHI " VICE PRESIDENT 47' Pamrt Numbe,(For bml use cely) 473 Permit Approvd(Forloalwce y) 474 PermitF Pieminn Oate(Fnr Baalu c only) 475 PT0003999 EE0003804 12/31/1993 12:00:OOAM UPCF(12/99 revised)