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~ UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />aaaaaaaaaUNDERGROUND STORAGE TANKS -TANK PAGE 2 <br />SINGLE WALL PIPING <br />r3rIND::�uNs RDCTION Cherkal;ru< <br />PRESSURIZED PIPING (Check all that <br />r/✓ G-. 4M SINGLE WALL PIPING <br />apply): 467. <br />0 1. ELECTRONIC LME LEAK DETECTOR <br />SHUT-OFF <br />ERGROUND PIPING <br />FOR LEAK, SYS <br />OMLE <br />LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br />FAILURE, AND SYSTEM DISCONNECTION <br />I q AND VISUAL AL <br />SYSTEM TYPE ❑ I. PRESSU <br />r�,r SUCTION <br />""`� <br />ABOVEGROUNDPIPING <br />❑ 3. CRAVf1Y <br />03. ANNUAL INTEGRITY TEST (0. <br />CONSTRUCTION/ <br />MANUFACTURER - SINGLE <br />ALL ❑ 3, LINED TRENCH <br />45a. ❑ I. PRESSURE ❑ <br />❑ 99. OTHERQ'1. <br />2. SUCTION ❑ 3. GRAVITY <br />459 <br />Q 2. DI UBL <br />WALL ❑ 95. UNKNOWN <br />SINGLE WALL <br />0 95. UNKNOWN <br />462. <br />MANUFACTU <br />�/��� <br />❑ 2. DOUBLE WALL <br />0 99. OTHER <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />ZKBARESTEEL C1 6. FRP <br />MPATIBLE W/100%METHANOL463. <br />461 MANUFACTURER <br />0 1. BARE STEEL <br />GRAVITY FLOW (Check all Out apply): <br />❑ 2. STAINLESS STEEL ❑ 7. GAL <br />1ANIZED STEEL <br />0 2. STAINLESS STEEL <br />Q 6. FRP COMPATIBLE W/100% <br />METHANOL <br />❑ 3. PLASTIC COMPATIBLE WITH <br />ON NIS ❑ 95. UNKNOWN <br />❑ 3. PLASTIC COMPATIBLE W/CONTENTS <br />❑ 7. GALVANIZED STEEL <br />CONTINUOUS TURBINE SUMP SENSOR W ITH AUDIBLE AND VISUAL <br />ALARMS AND (Chink one) <br />❑ 4. FIBERGLASS Q S. FL <br />(HDPE) ❑ 99, OTHER <br />0 4. FIBERGLASS <br />0 S. FLEXIBLE (HDPE) <br />0 99. OTHER <br />Q 5. STEEL W/COATING [19. CA <br />OLE <br />ODIC PROTECTION 464. <br />❑ 5. STEEL W/COATING <br />Q 9. CATHODIC PROTECTION <br />Q 11. AUTOMATIC LEAK DETECTOR <br />-ti'IL,P I <br />l^v:LEdKDEB'EOTIONree.�><.rcsu; <br />., <br />.Q 95. UNKNOWN <br />465. <br />SINGLE WALL PIPING <br />/0/ ABOVEGROUND PIPING <br />PRESSURIZED PIPING (Check all that <br />r/✓ G-. 4M SINGLE WALL PIPING <br />apply): 467. <br />0 1. ELECTRONIC LME LEAK DETECTOR <br />SHUT-OFF <br />3.0 GPH TEST PRESSURIZED PIPING (Check all that apply): <br />Q 1. ELECTRONIC <br />FOR LEAK, SYS <br />OMLE <br />LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br />FAILURE, AND SYSTEM DISCONNECTION <br />I q AND VISUAL AL <br />S. SHUT OFF FOR LEAK, SYSTEM FAILURE, AND SYSTEM DISCONNECTION <br />[12. MONTHLY 0.2 GPH TEST <br />+AUDIBLE AND VISUAL ALARMS. <br />03. ANNUAL INTEGRITY TEST (0. <br />0 2. MONTHLY 0.2 GPH TEST <br />1 GPH) <br />Q3. ANNUAL INTEGRITY TEST (0. 1 GPH) <br />CONVENTIONAL SUCTION SYSTEA <br />S 04. DAILY VISUAL CHECK <br />0 5. DAILY VISUAL MONITORING <br />OF PUMPING SYSTEM +TRIENNIAL PIPING CONVENTIONAL SUCTION SYSTEMS (Check all that apply) <br />INTEGRITY TEST (0.1 GPH) <br />05- DAILY VISUAL MONITORING OF PIPING AND PUMPING <br />SAFE SUCTION SYSTEMS (NO VALN <br />SYSTEM <br />ES IN BELOW GROUND PIPING): 136. TRIENNIAL <br />07. SELFMONITORINO <br />INTEGRITY TEST (0.1 GPH) <br />GRAVITY FLOW <br />SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): <br />119. BIENNIAL INTEGRITY TEST (0 <br />117. SELF MONITORING <br />I GPH) <br />GRAVITY FLOW (Check all Out apply): <br />Q S. DAILY VISUAL MONITORING <br />SECONDARILY CONTAINED PTNG <br />/ ` 09. BIENNIAL 1NTEGRITy TEST (O.I GPH) <br />PRESSURIZED PIPING (Check EII that <br />i <br />N <br />ply); SECONDARILY CONTAINED PIPING/ <br />10. CONTINUOUS TURBINE SUM <br />PRESSURIZED PIPING (Check all Out apply): <br />SENSOR H' H AUDIBLE AND VISUAL 10. <br />ALARMS AND (Check oae) <br />Q a. AUTO PUMP SHUT OFF <br />CONTINUOUS TURBINE SUMP SENSOR W ITH AUDIBLE AND VISUAL <br />ALARMS AND (Chink one) <br />0 It. AUTO PUMP SHUT OFF FOR <br />N A LEAK OCCURS <br />Q a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br />LEAKS, SYSTEM FAILURE <br />DISCONNECTION <br />AND SYSTEM 0 b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM <br />00. NO AUTO PUMPSHUTOF <br />FAILURE AND SYSTEM <br />DISCONNECTION <br />Q 11. AUTOMATIC LME LEAK D <br />OR (3.0 GPH TEST) WITH FLOW SHUT 0o' NO AUTO PUMP SHUT OFF <br />OFF OR RESTRICTION <br />Q 11. AUTOMATIC LEAK DETECTOR <br />O 12. ANNUAL INTEGRITY TEST (0.1 <br />PH) <br />SUCTION/GRAVTfY SYSTEM <br />❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) <br />Q 13. CONTINUOUS SUMP SENSOR+ <br />SUCTION/GRAVITY SYSTEM <br />kUDIBLE AND VISUAL ALARMS <br />EMERGENCY GENERATORS ONLY (Check <br />013. CONTINUOUS SUMP SENSOR+ AUDIBLE AND VISUAL ALARMS <br />all Out apply) <br />014. CONTINUOUS SUMP SENSORAUTO <br />,W <br />AUDIBLE AND VISUAL AL <br />THOUT PUMP SHUT OFF EMERGENCY GENERATORS ONLY (Check all that apply) <br />❑ 14. CONTINUOUS SUMP SENSOR <br />015. AUTOMATIC LINE LEAK DETCTOR <br />WTTHp l�T AUTO PUMP SHUT OFF <br />(3.0 GPH TEST) WITHOUT FLOW AUDIBLE AND VISUAL ALARMS <br />SHUT OFF OR RESTRICTION <br />016. ANNUAL INTEGRITY TEST (0,1 <br />Q 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) <br />PH) <br />Q 17. DAILY VISUAL CHECK <br />QI6. ANNUAL INTEGRITY TEST (0.1 GPH) <br />0 I7. DAILY VISUAL CHECK <br />ikrll ;N9 RI�I?LYi?Cf411I?I , <br />DISPENSER 46a. <br />01. FLOAT MECHANISM THAT <br />STALLETAMMENT <br />DATE/ INSTAnnLLED <br />SHUTS OFFSHEAR VALVE <br />02. CONTINUOUS DISPENSER PAN SENSOR+ AUDIBLE AND VISUAL ALARMS 04. DAILY VISUAL CHECK 469. <br />❑ 5. <br />v1GN <br />TRENCH/LINER MONITORING <br />[13. CONTINUOUS DISPENSER PAN SENSOR WRH AUTO SHUT OFF FOR <br />DISPENSER + AUDIBLE AND VISUAL CABINS .NONE <br />kx,O j`N .Lj(U`,P iiAxOR5IGNATUR>;!. <br />I certify that the Information provided h <br />rein is We and accurate to the best of my kn.W Mv. <br />We <br />use 0Ny) 475. <br />UPCF hwfwrc-6 (1/99) -3/4 11HP://www.unidomm <br />Rev. 02/I6/00 <br />