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y IFIED PROGRAM CONSOLIDATED FOWM- TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of VI. PIPING CONSTRUCTION (Check 91 that t) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE . PRESSURE 0 2. SUCTION ❑ 3. GRAVITY 458, 0 1. PRESSURE [12. SUCTION [13. GRAVITY 459. CONSTRUCTION/ EVIL. NGLE WALL ❑ 3. LINED TRENCH [199. OTHER 460. ❑ 1. SINGLE WALL [195. UNKNOWN 462, MANUFACTURER OUBLE WALL [195. UNKNOWN [12. DOUBLE WALL [199. OTHER MANUFACTURER . ` 46). MANUFACTURER 463. ❑ L BARE STEEL 0 6. PRP COMPATIBLE W/100% METHANOL [11. BARE STEEL 0 6. FRP COMPATIBLE W/100% METHANOL [:12. STAINLESS STEEL 0 7. GALVANIZED STEEL 0 2. STAINLESS STEEL 0 7. GALVANIZED STEEL 3.9tASTIC COMPATIBLE WITH CONTENTS 0 95. UNKNOWN 0 3. PLASTIC COMPATIBLE W/ CONTENTS 0 8. FLEXIBLE (HDPE) [199. OTHER It -T44.. FIBERGLASS [18. FLEXIBLE (HDPE) [199. OTHER [14. FIBERGLASS 1:19. CATHODIC PROTECTION 0 5. STEEL W/COATING 0 9. CATHODIC PROTECTION 464 [15. STEEL W/COATING 0 95. UNKNOWN 465. VD. PIPING LEAK DETECTION (check all Naze 1 (A dacrition of the monitoring cc A.11 be submitted m Ne local .) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 46a 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 ❑ L ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM AUTO PUMP SHUT-OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK SYSTEM FAILURE, AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. [12. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST [13. ANNUAL INTEGRITY TEST (0.1 GPH) [13. ANNUAL INTEGRITY TEST (0.1 GPH) [34. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ S. DAILY VISUAL MONITORING OF PUMPING SYSTEM + TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS MO VALVES IN BELOW GROUND PIPING): [36. TRIENNIAL INTEGRITY TEST (OA GPH) []7. SELF MONITORING SAFE SUCTION SYSTEMS MO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW 0 7. SELF MONITORING E19. BIENNIAL INTEGRITY TEST (0.1 GPH) GRAVITY FLOW (Check all that apply): 0 S. DAILY VISUAL MONITORING 09. BIENNIAL INTEGRITY TEST (O.1 GPI) 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 SENSORTy TH AUDIBLE AND VISUAL A�Lp/g�.(S AND (Check ore) AL S AND (Check one) ;gr UTO PUMP SHUT OFF WHEN A LEAK OCCURS UTO PUMP SHUT OFF WHEN A LEAK OCCURS E AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION [3c. NO AUTO PUMP SHUT OFF Oc. NO AUTO PUMP SHUT OFF M/1'1. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT 0 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION W2_ ANNUAL INTEGRITY TEST (0.1 GPH). ANNUAL INTEGRITY TEST (0.1 GPH) SUCTION/GRAVITY SYSTEM UC N/GRAVITY SYSTEM [113. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS 3. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Check all that apply) EMERGENCY GENERATORS ONLY (Check all that apply) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114. CONTINUOUS SUMP SENSOR WITH OITT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW 015. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) SHUT OFF OR RESTRICTION . ANNUAL INTEGRITY TEST (0.1 GPH) [116. ANNUAL INTEGRITY TEST (0.1 GPH) 0 17. DAILY VISUAL CHBCK [117. DAILY VISUAL CHECK VTR. DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. O1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04. DAILY VISUAL CHECK 469. DATE INSTALLED 0 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCH/LINER MONITORING ') By CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR O6. NONE !! DISPENSER + AUDIBLE AND VISUAL ALARMS IX. OWNER/OPERATOR SIGNATURE I certify that the information provided and accurate to the best of my knowledge. S F BRAT DATE; 470' 472. NA_h,E FOWNE OPERAT R( % Lam, 'C)7'l..E _OF OWN P lPcm»t Number (Agency use only) 473 1 Permit Approve By (Agency me only) 474. 1 Permit Expiration Date (Agency use only) 475. UPCF bwfwm-b (1/99) - 3/4 www.unidocs.org Rev. 02/16/00