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�IFIED PROGRAM CONSOLIDATED FORTANK: TA0515639 110 PR #: PRO231595 as FAC #: FA0003591 UNDERGROUND STORAGE TANKS - TANK PAGE 2 VL PIPING CONSTRUCTION (check all Nm apply) P., 7 of UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ® 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 458 ❑ I. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY 459 CONSTRUCTION ❑ 1. SINGLE WALL [:13 . LINED TRENCH ❑ 99. OTHER 460 ❑ 1. SINGLE WALL ❑ 95. UNKNOWN 462 ® 2. DOUBLE WALL ©95. UNKNOWN ❑ 2. DOUBLE WALL ❑ 99. OTHER MANUFACTURER A O SMITH abl MANUFACTURER 463 ❑ 1. BARE STEEL ® 6. FRP COMPATIBLE./ 106°6 METHANOL ❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE x/ I W9: METHANOL [12. STAINLESS STEEL [17. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL ❑ PLASTIC COMPATIBLE W/ CONTENTS [195. UNKNOWN ❑ PLASTIC COMPATIBLE W/ CONTENTS ❑ 95. UNKNOWN ❑ 4. FIBERGLASS ❑ S. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION 464 ❑ 5. STEEL W/COATING ❑ 9. CATHODIC PROTECTION �5 VIL PIPING LEAK DETECTION (Check all thatapply)(A d peon ofthe mmitecM pwR ,fall he cohmiacato the Iuea1aernry) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING (Cheek all that apply): PRESSURIZED PIPING (Check all that apply): ❑ I. 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 CONVENTIONAL SUCTION SYSTEMS (Check all that apply) ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPMG SYSTEM INTEGRITY TEST (0.1 GPH) ❑ 6. 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 ❑ 9. BIENNIAL INTEGRITY TEST (0.1) GPH GRAVITY FLOW (Check all that apply): [18. 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 (Chukane) ALARMS AND (Chuekom) ❑ 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 UT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ® I1. AUTOMATIC LINE LEAK DETECTOR (3.0 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 ((Mcck all del.11y) EMERGENCY GENERATORS ONLY (Check A] wt 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 FLAW ❑ 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 VII. DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ I. 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 DISPENSER + AUDIBLE AND VISUAL ALARMS 40 13L OWNERIOPERATOR SIGNATURE I wtilk that Ra infmmatian pmvidel heccin is true an4 seaway to the bcst ofrayk vjcdv' SIGNATURE OF OWNER/OPERATOR DATE 470 NAME OF OWNER/OPERATOR (print) TITLE OF OWNRR/OPERATOR AMARJIT SINGH 471 OWNER 47' Petmit Numbs (Fm ]mel ux onW) 473 Pemet App,oveE(Foe lues] use anh) 474 Permit Expiration Dalc(Fm lwl use anh) 475 PT0003666 EE0000817 12/31/1999 12:00:OOAM UPCF (12/99 revised)