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UnFIED PROGRAM CONSOLIDATED FORIbiw <br />TANKS <br />UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />VDL DISPENSER CONTAINMENT <br />SYSTEM TYPE 5714PRESSUELE D 2. SUCTION <br />O 3. GRAVITY 458. D L PRESSURE O 2. SUCTION O 3. GRAVITY <br />459. <br />CONSTRUCTION/ D 1. SINGLE WALL D 3. LINED TRENCH <br />[199. OTHER 460. O 1. SINGLE WALL <br />O 95. UNKNOWN <br />462. <br />MANUFACTURER DOUBLE WALL O 95. UNKNOWN <br />O 2. DOUBLE WALL <br />O 99.OTHER <br />05. TRENCH/LINER MONITORING <br />MANUFACTURER <br />461. MANUFACTURER <br />463. <br />D 1. BARE STEEL D 6. FRP COMPATIBLE W/100%METHANOL❑ <br />L BARE STEEL <br />C1 6. FRP COMPATIBLE W/100%METHANOL <br />O 2. STAINLESS STEEL O 7. GALVANIZED STEEL <br />O 2. STAINLESS STEEL <br />D 7. GALVANIZED STEEL <br />3. PLASTIC COMPATIBLE WITH CONTENTS D 95. UNKNOWN <br />D 3. PLASTIC COMPATIBLE W/ CONTENTS <br />D 8. FLEXIBLE (HDPE) <br />[199. OTHER <br />�D <br />243.. FIBERGLASS [18. FLEXIBLE (HDPE) [199. OTHER <br />[14. FIBERGLASS <br />[19. CATHODIC PROTECTION <br />D 5. STEEL W/COATING O 9. CATHODIC PROTECTION 464. <br />O 5. STEEL W/COATING <br />D 95. UNKNOWN <br />465. <br />SINGLE WALL PIPING 466. <br />PRESSURIZED PIPING (Check all that apply): <br />O 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br />SHUT-OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION <br />+AUDIBLE AND VISUAL ALARMS. <br />[12. MONTHLY 0.2 GPH TEST <br />[13. ANNUAL INTEGRITY TEST (0.1 GPH) <br />CONVENTIONAL SUCTION SYSTEMS <br />❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING <br />INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />O 7. SELF MONITORING <br />GRAVITY FLOW <br />[39. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />AL S AND (Check one) <br />a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />96, AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />Oc. NO AUTO PUMP SHUT OFF <br />el <br />�/ <br />p 11. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT <br />OFF OR RESTRICTION <br />5212. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM <br />D 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />D 14. CONTINUOUS SUMP SENSOR WITH AUTO PUMP SHUT OFF <br />AUDIBLE AND VISUAL ALARMS <br />[115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW <br />1/A, SHUT OFF OR RESTRICTION <br />WI6. ANNUAL INTEGRITY TEST (0.1 GPH) <br />O 17. DAILY VISUAL CHECK <br />SINGLE WALL PIPING 461 <br />PRESSURIZED PIPING (Check all that apply): <br />❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br />SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION <br />+AUDIBLE AND VISUAL ALARMS. <br />02. MONTHLY 0.2 GPH TEST <br />O 3. ANNUAL INTEGRITY TEST (0.1 GPH) <br />[14. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS (Check all that apply) <br />05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />06. TRIENNIAL INTEGRITY TESTMI GPH) <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />O 7. SELF MONITORING <br />GRAVITY FLOW (Check all that apply): <br />O 8. DAILY VISUAL MONITORING <br />E19. BIENNIAL INTEGRITY TEST (0.1 GPH) <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Check all that apply): <br />10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br />AL45.-AU AND (Check <br />AUTO PUMP SHUT <br />OFF WHEN A LEAK OCCURS <br />AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />Oc. NO AUTO PUMP SHUT OFF <br />D 11. AUTOMATIC LEAK DETECTOR <br />2. ANNUAL INTEGRITY TEST (0.1 GPH) <br />CTION/GRAVITY SYSTEM <br />peCONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />[114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br />AUDIBLE AND VISUAL ALARMS <br />D 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) <br />[116. ANNUAL INTEGRITY TEST (0.1 GPM) <br />O 17. DAILY VISUAL CHECK <br />I I IX. OWNERIOPERATOR SIGNATURE I <br />I certify that the information pr4yided-heWin is true_and accurate to the best of my knowledge. I <br />DATE: <br />473 <br />UPCF hwfwrc-b (1/99) - 314 www.unidocs.org Rev. 02/16/00 <br />VDL DISPENSER CONTAINMENT <br />DISPENSER CONTAINMENT <br />468. <br />❑ 1. <br />FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE <br />O 4. DAILY VISUAL CHECK469. <br />DATE INST, LLED <br />02 <br />CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS <br />05. TRENCH/LINER MONITORING <br />CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR <br />O6. NONE <br />I I IX. OWNERIOPERATOR SIGNATURE I <br />I certify that the information pr4yided-heWin is true_and accurate to the best of my knowledge. I <br />DATE: <br />473 <br />UPCF hwfwrc-b (1/99) - 314 www.unidocs.org Rev. 02/16/00 <br />