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�FIED PROGRAM CONSOLIDATED FORM• TANK: TA0515638 PRO: PRO231595 FAC O: FAOW3591 UNDERGROUND STORAGE TANKS - TANK PAGE 2 VI. PIPING CONSTRUCTION ([neck all Nat apply) Pagc 5 oft UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® I. PRESSURE ❑ 2. SUCTION [13. GRAVITY 458 ❑ I. PRESSURE ❑ 2. SUCTION [-13. GRAVITY 459 CONSTRUCTION ❑ 1. SINGLE WALL 03. LINEDTRENCH ❑ 99. OTHER 460 ❑ I. SINGLE WALL ❑ 95. UNKNOWN 462 912. DOUBLE WALL ®95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. OTHER 463 MANUFACTURER A O SMITH 461 MANUFACTURER ❑ L BARE STEEL ❑ 6. FRP COMPATIBLE w/ loo . METHANOL ❑ 1. BARE STEEL [16. FRP COMPATIBLE w/ 1908 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 ❑ S. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) [199, OTHER ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 [15. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 465 VIL PIPING LEAK DETECTION(cMk mi wt apph)(A&scripum afore aaaitasinepsoeam stall x submitted w the local ae 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 ❑ I. 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 (Check.11 that apply) CONVENTIONAL SUCTION SYSTEMS ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING INTEGRITY TEST (0.1 GPH) ❑ b. 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 GRAVITY FLOW (Check all that apply): ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH ❑ 8. 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 (Clack.) ALARMS AND (Cluck.) [3a. AUTO PUMP SHUT OFF WREN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS E] 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 LINE LEAK DETECTOR (30 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 ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY (Cluck 91 mn apyly) EMERGENCY GENERATORS ONLY(Cn JI 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) WITHO T FLOW ❑ ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW OR RESTRICTION SHUT OFF OR RESTRICTION SHUT OFF ❑ 16. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 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 DATE INSTALLED 468 ❑ 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 469 DISPENSER +AUDIBLE AND VISUAL ALARMS DL OWNER/OPERATOR SIGNATURE Ir Athat the iN'am mpmviG Mein is Due and acmaw to the best of my kn9wlwvg SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR (pant) TITLE OF OWNER/OPERATOR 472 411 AMARJIT SINGH OWNER P.,N.(Foflocalusamly) 473 Permit Appm,eJ(Fmlocaluse.h) 474 Pmmit Ep'am Date (Fm local use only) 475 EE0004006 7/31/2006 12:00:OOAM PT0016590 UPCF (12/99 revised)