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WNIFIED PROGRAM CONSOLIDATED FOW <br />TANKS <br />UNDERGROUND STORAGE TANKS - TANK PAGE 2 <br />SYSTEM TYPE N 1. PRESSURE 0 2. SUCTION <br />[13. GRAVITY 451 L FRRHSSURS ❑ 2. SUCTION ❑ 3. GRAVITY <br />4".. <br />CONSIRUCTIOW 0 1. SINGLE WALL ❑ 3. LINED TRENCH <br />❑ 99. OTHER 460 ❑ 1. 9INGLE WALL <br />1395. UNKNOWN <br />461 <br />MANUFACTURER <br />®2 WIIID.E WALL ❑ 95. UNKNOWN <br />❑ 21)OUBLB WALL <br />❑ 99. OTHER <br />MANUFACTURER <br />461. MANUFACTURES <br />463. <br />❑ 1. BARE STEEL ❑ 6. FRP COMPATIBLE W/100%MEIEANOL <br />13 1. BARS SIERT.FRP <br />[3 6. COMPATIBLE W/100%MHTHANOL <br />❑ 2 STAINLESS STEEL ❑ 7.OALVANIZEO STEEL. <br />13 2 STAINLESS STEEL <br />[37. GALVANIZED) STEEL <br />(33. PLASTIC COMPATIBLE WITH CONTENTS 95. UNKNOWN <br />[13. PLASTIC COMPATIBLE W/ CONTENTS <br />❑ S. FLEXIBLE a (HOPE) <br />❑ 99. OTHER <br />In 4. FIBERGLASS ❑ S. FLEXIBLE (HDPE) ❑ 99. OTHER <br />❑ 4. FIBERGLASS <br />❑ 9. CATHODIC PROTECTION <br />❑ 5. STEEL W/COATINO [39. CATHODIC PROTBCTION 464 <br />❑ 5. STEEL W/COA7TNG <br />[195. UNKNOWN <br />465. <br />SINGLE WAIL PANG 466 <br />PRESSURIZED PIPING (Check all tb d apply): <br />0 1. ELECTRONIC 12M LRAK DETECTOR 3.0 OPH TEST MW AUTO PUMP <br />SHUT-0FF FOR IEAK SYSTEM FAILURE, AND SYSTEM DISCONNECTION <br />+ADDIBLE AND VISUAL ALARMS. <br />❑ 2 MONTHLY 0.2 OPH TEST <br />3. ANNUAL INTEGRITY TEST(0.I OPH) <br />13 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+ TRIENNIAL PIPING <br />INTEGRITY TEST (0.1 GPH) <br />SAFE SUCTION SYSTEMS (NO VALVES IN BffiAW GROUND PIPING) - <br />❑7. SEP MONITORING <br />GRAVTTYFLOW <br />09. BDM41AL INTEGRITY TEST (0.1 OPH) <br />SECONDARILY CONTAINED APING <br />PRESSURIZED PIPING (Cheat W tot apply): <br />10 OONDNUOUS TURBINE SUMP SEN30R 1h= AUDIBLE AND VISUAL <br />ALARMS AND (Cork ®) <br />IM a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM <br />DISCONNECTION <br />Q9. NOAUlOPUMPSHUTOFP <br />❑ 11. AUTOMATIC LINE LEAK DEFECTOR (3.0 OPH TEST) NM FLOW SCOT <br />OFF OR RESTRICTION <br />1311 ANNUAL INTEGRITY TEST (0.1 OPTi) <br />SUCTION0GRAVIY SYSTEM <br />❑ 13. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Cock AD that apply) <br />❑ 14. CONTINUOUS SUMP SENSOR WITH AUTO TRAP SHUT OFF <br />AUDIBLE AND VISUAL ALARMS <br />❑ 15. AUTOMATIC LINE I BAK DETECTOR (3.0 OPH TEST) WITHOUT FLOW <br />SHUT OFF OR RESTRICTION <br />1316 ANNUAL INTEGRITY TEST (0.1 OFM <br />[317. DAILY VISUAL CHECK <br />SINGLE WAIL PIPING 467. <br />PRESSURIZED PIPING(Cbmk rU the apply): <br />[31. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST MM AUTO PUMP <br />SIUf OFF 1UR ILSAK, SYSTEM FAILURS. AND SYST13MDISCONN13MON <br />+AUDIBLE AND VISUAL ALARMS. <br />❑ 2 MONTHLY 0.2 GPH,.ST <br />[33. ANNUAL INTEGRITY TEST (0.1 OPS) <br />[34. DAILY VISUAL CHECK <br />CONVENTIONAL SUCTIONSYSTEMS (Cheak.V tart apply) <br />[35. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br />❑ 6. TRIENHIAL INTB iRITY TBSI (0.l GPH) <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />[3 7. SELF MONITORING <br />GRAVITY PLOW (Cheek all tar ryply)- <br />❑ S. DAILY VISUAL MONITORING <br />9. BIENNIAL INTEGRITY TEST (Ol GFE ) <br />SECONDARILY CONTAINED PIPING <br />PRESSURIZED PIPING (Che -k.11 that apply): <br />10 CONTINUOUS TURBINE SUMP SENSOR MM AUDIBLE AND VISUAL <br />ALARMS AND (Cork ane) <br />0 a. AUTO PUMP SHUT OFF WHEN A I,BAR OCCURS <br />❑ b. AUTO PUMP SNI OFF FOR LBAKs. SYSTEM FAILURE AND SYSTEM <br />DISCONNEI T1ION <br />Do, NO AUTO PUMP SNC OFF <br />❑ 11. AUTOMATIC LEAK DETBCTOR <br />12 ANNUAL INTEGRITY TEST (0.1 OPH) <br />[313. CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Cheat an that apply) <br />1314. CONTINUOUS SUMP SENSOR WiTHOIJf AUTO PUMP SHUT OFF <br />AUDIBLE AND VISUAL ALARMS <br />❑ 15. AUTOMATIC IBNR 7 BAK DETECTOR (3.0 OPS TEST) <br />❑ I6 ANNUAL INTEGRITY TEST (0.1 GPH) <br />❑ 17. DAILY VISUAL CHECK <br />DISPENSER CONTAINAfE4T 461 1 ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK 469. <br />DATE INSTALLED [32. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE ACID VISUAL ALARMS ❑ 5. TRENCWL24 t MONITORING <br />®3. CONTINUOUS DISPENSE PAN SENSOR ME AUTO SNUT OFF FOR <br />PvS .RFII+AIS MIR AT Vt41TAl. At AVT [3 6. NONE <br />L M OWNER/OPERATOR SIGNATURE -- --- <br />I autifY tht Wa mfo mtim 11nV141ed herein is hna and acaute: to the but ofmv knowlodaa <br />AM D 47U <br />NAMM80PQWN Hit-,ATOR(p to 1"4 <br />Paint N3mTITLE OF OWNEP/OPEUTOR: �(� <br />^` 472 <br />Fbr (Agency me aNy) 473 Parent Appwad By (Agency w only) 474 1 Permt Expi Date (Agency ve <br />only) 475. <br />UPCF bwha"(LSF)-314 httpJ/w umidemori Ron. WA16 9 <br />