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/ TANK: A0438304 � T �NIFIED PROGRAM CONSOLIDATED FOR PR#: PR0234383 �/- FAC#: FA0003670 UNDERGROUND STORAGE TANKS - TANK PAGE 2 r s VI.PIPING CONSTRUCTION(LTark 0 that appy) Pages I UNDERGROUND PIPING ABOVEGROUND PING SYSTEM TYPE ❑ 1.PRESSURE M 2.SUCTION ❑ 3.GRAVITY 458 ❑ 1.PRESSURE [12.SUCTION [13.GRAVITY F ❑1.SINGLE WALL ❑3.LINED TRENCH ❑ 99.OTHER 4W ❑ 2.DOUBLE WA1.SINGLE LL ❑99.OTHER WN®2.DOUBLE WALL ❑95.UNKNOWN ml RER MANUFACTURER EEL ❑6.FRP COMPATIBLE W 100'6 METHANOL 1.BARE STEEL ❑ 6.FRP COMPATIBLE W 100%METHANOLESS STEEL ❑ 7.GALVANIZED STEEL ❑2.STAINLESS STEEL ❑ 7.GALVANIZED STEELOMPATIBLEW/CONTENTS ❑ 95.UNKNOWN ❑ PLASTIC COMPATIBLE W/CONTENTS ❑95.UNKNOWN LASS ❑S.FLEXIBLE(HDPE) ❑ 99.OTHER ❑4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) [-199.OTHER ❑ 5.STEEL W/COATING ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 VU.PIPING LEAK DETECTION(Clack Al he epply)(AdemNtloO eT@ematitormgPm sha0 besoboiuci m twos] y.) UNDERGROUND PIPING ABOVEGROUND PIPING S[NGLEWALLPIPING 46SINGLEWALLPING 467 rPRESSUMZEDIPING(Check aB Nat apply): PRESSURIZED PIPING(Check all that apply): NIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF ❑ I.ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT OFF SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEAK,SYSTEM FAILURE.AND SYSTEM DISCONNECTION+AUDIBLE AND ARMS. VISUAL ALARMS. Y 0.2 GPH TEST2.MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) INTEGRITY TEST(0.1 GPH) ❑4,DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply) CONVENTIONAL SUCTION SYSTEMS ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNTEAL PIPING INTEGRITY TEST(0.1 GPH) [16.TRIENNIAL INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPBING): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ 7.SELF MONITORING ❑7.SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑9.BIENNIAL INTEGRITY TEST(0.1)GPH ❑ R.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(LTck.) ALARMS AND(Chale oat) ❑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 SHUT OFF ❑c.NO AUTO PUMP SHUT OFF ❑ 11.AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR ❑ 11 AUTOMATIC LEAK DETECTOR RESTRICTION ❑ U.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(Chale all tW apply) EMERGENCY GENERATORS ONLY(Clack all tIoU appy) ❑ 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 El SHUT AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW ❑ 15.AUTOMATIC LME LEAK DETECTOR(3.0 GPH TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPH) ❑ 17.DAILY VISUAL CHECK ❑ 17.DAILY VISUAL CHECK VID.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 ❑ S.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE 469 DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE 1 catiyt 0a iNmwim provi Meta h ma aM ecmetc to the bet ofW k 0%c, 470 SIGNATURE OF OWNER/OPERATOR DATE NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 472 CHARLES BUSALACCHI 471 VICE PRESIDENT Permit Appm (Fm1kalascmlY) 474 Permit Fapiatim Dne(For lout aem1Y) 475 Permit Nu3 areoaN) 673 PT000003999 EE0003804 12/31/1993 12:00:OOAM UPCF(12/99 revised)