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MFh1FIED PROGRAM CONSOLIDATED FOM 11 <br />TANKS <br />UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br />UNDERGROUND PIPING <br />ABOVEGROUND PIPING <br />SYSTEM TYPE . PRESSURE D 2. SUCTION <br />[13. GRAVITY 458. D L PRESSURE D 2. SUCTION [13. GRAVITY <br />459. <br />CONSTRUCTION/ D 1. SINGLE WALL D 3. LINED TRENCH <br />D 99. OTHER 460. [11. SINGLE WALL <br />D 95. UNKNOWN <br />462. <br />MANUFACTURER /DOUBLE WALL D 95. UNKNOWN <br />[12. DOUBLE WALL <br />D 99, OTHER <br />MANUFACTURER <br />461. MANUFACTURER <br />463. <br />❑ 1. BARE STEEL D 6. FRP COMPATIBLE W1100% METHANOL <br />[11. BARE STEEL <br />[16. FRP COMPATIBLE W/1 00% METHANOL <br />D 2. STAINLESS STEEL D 7. GALVANIZED STEEL <br />[12. STAINLESS STEEL <br />D 7. GALVANIZED STEEL <br />113. PLASTIC COMPATIBLE WITH CONTENTS ❑ 95. UNKNOWN <br />D 3. PLASTIC COMPATIBLE W/ CONTENTS <br />D B. FLEXIBLE (HDPE) <br />D 99. OTHER <br />if-` FIBERGLASS D 8. FLEXIBLE (HDPE) D 99. OTHER <br />[14. FIBERGLASS <br />D 9. CATHODIC PROTECTION <br />D 5. STEEL W/COATING D 9. CATHODIC PROTECTION 464, <br />[15. STEEL W/COATING <br />D 95, UNKNOWN <br />465. <br />SINGLE WALL PIPING 466 <br />PRESSURIZED PIPING (Check all that apply): <br />D L 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 />03. ANNUAL INTEGRITY TEST (0.1 GPH) <br />CONVENTIONAL SUCTION SYSTEMS <br />D 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 />D 7. SELF MONITORING <br />GRAVITY FLOW <br />[19. 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 />ALARMS AND (Check one) <br />e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />96, AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM, <br />DISCONNECTION <br />Dc. NO AUTO PUMP SHUT OFF <br />ell. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITH FLOW SHUT <br />�/ OFF OR RESTRICTION <br />1 <br />J2(12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />SUCTION/GRAVITY SYSTEM j <br />D 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS 6 <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 />DIL5 AUTOMSHUT ATIC <br />LINERESTLEAK ITHOUT <br />DETECTOR (3.0 GPH TEST) W <br />,' FLOW <br />d16. ANNUAL INTEGRITY TEST (0.1 GPH) <br />D 17. DAILY VISUAL CHECK <br />SINGLE WALL PIPING 47. <br />PRESSURIZED PIPING (Check all that apply): <br />D I. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST EIM 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 />03. ANNUAL INTEGRITY TEST (0.1 GPH) <br />[14. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTION SYSTEMS (Check all that apply) <br />[15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />E36. TRIENNIAL INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />D 7. SELF MONITORING <br />GRAVITY FLOW (Check all that apply): <br />[18, DAILY VISUAL MONITORING <br />D 9. 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 />AUS AND (Cheek one) <br />AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />Dc. NO AUTO PUMP SHUT OFF <br />D 11. AUTOMATIC LEAK DETECTOR <br />r12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />CTION/GRAVITY SYSTEM <br />I5. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check all that apply) <br />D 14. 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 GPH) <br />D 17. DAILY VISUAL CHECK _ <br />DISPENSER CONTAINMENT46S. D1. FLOATMECHANISM THATSHUTSOFF SHEARVALVE 04. DAILY VISUAL CHECK 469. <br />DATE INST%I�+'LLED 02 CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH/LINER MONITORING <br />I Int. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR D6. NONE <br />IX. OWNER/OPERAl UK 51UMAX UJM <br />I certify that the information pr in is tmVnd accurate to the best of my knowledge. <br />nen <br />DATE: <br />473. <br />UPCF hwfwrc-b (1/99) - 3/4 www.unidocs.org Rev. 02/16/00 <br />