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r _ /Q�� ABOVEGROUND PIPING 4� SINGLE WALL PIPING PRESSURIZED PLpING(Che9kallthat apply): 14 467. Q 1. ELECTRONIC LME LEAK DETECTOR SHUT-0FF 3.0 GPH TEST PRESSURIZED PIPING (Check all that apply): 1. FOR LEAK, SYS + AUDIBLE AND VISUAL UNIFIED PROGRAM CONSOLIDATED FORM ❑ 2. MONTHLY GPH TEST 0.2 AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. TANKS ❑ 2. MONTHLY 0.2 GPH TEST 1 GPH) DERGROUND STORAGE TANKS - TANK PAGE 2 CONVENTIONAL SUCTION SYSTEMS 'Vd. PIpINCi`C.(?�'S�°RUGfIOP(€ittkal tF:' I - Pa c of OF PUMPING SYSTEM. CONVENTIONAL SUCTION SYSTEMS (Cheek all that apply) TRIENNIAL PIPING DERGROUND PIPING ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM SYSTEMTYPE ❑ 1. PRE$SU ABOVEGROUND PIPING a+T SUCTION "'"� ❑ 3. GRAVITY CONSTRUCTION/ a , MANUFACTURER � SINGLE 45f. ❑ 1. PRESSURE ❑ ALL ❑ 3. LINED TRENCH ❑ 99. OTHER aha. 1. SINGLE WALL 2. SUCTION ❑ 3. GRAVITY 459. 02. DOUBLI WALL 095. UNKNOWN X95. UNKNOWN 461, MANUFACTU ,y �, 2. DOUBLE WALL (/A) "L 0 99. OTHER ZKBARESTEEL ❑6. FRP 461. MANUFACTURER MPATIBLE W/100%METHANOL465. 1. BARE STEEL ,!J ply): ✓✓ ' / SECONDARILY CONTAINED PIPING / 2. STAINLESS STEEL 7. GAL ANIZED STEEL CIS FRP COMPATIBLE W/I OOSL METHANOL 0 3. PLASTIC COMPATIBLE WITH ❑ 2. STAINLESS STEEL IONTENTS 1195. UNKNOWN ❑ 7. GALVANIZED STEEL ❑ 4. FIBERGLASS ❑ 8. FLE O 3. PLASTIC COMPATIBLE W/ CONTENTS ISLE (HDPE) ❑ 99. OTHER ❑ S. FLEXIBLE (HDPE) ❑ 99. OTHER ❑ 5. STEEL W/COATING 139. CA ❑ 4. FIBERGLASS ODIC PROTECTION 119 . CATHODIC PROTECTION OFF OR RESTRICTION 464. ❑ 5. STEEL W/COATING ❑ 95. UNKNOWN 465. SINGLE WALL PIPING _ /Q�� ABOVEGROUND PIPING 4� SINGLE WALL PIPING PRESSURIZED PLpING(Che9kallthat apply): 14 467. Q 1. ELECTRONIC LME LEAK DETECTOR SHUT-0FF 3.0 GPH TEST PRESSURIZED PIPING (Check all that apply): 1. FOR LEAK, SYS + AUDIBLE AND VISUAL ELECTRONIC LINE LEAK DETECTOR 3,0 GPH TEST WITH AUTO PUMP FAILURE, AND SYS DISCONNECTION S. SHUT OFF FOR LEAY, SYSTEM FAILURE, ❑ 2. MONTHLY GPH TEST 0.2 AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. 03. ANNUAL INTEGRITY TEST (0. ❑ 2. MONTHLY 0.2 GPH TEST 1 GPH) 03. ANNUAL INTEGRITY TEST (0. I GPH) CONVENTIONAL SUCTION SYSTEMS ❑ 4. DAILY VISUAL CHECK 05. DAILY VISUAL MONITORING OF PUMPING SYSTEM. CONVENTIONAL SUCTION SYSTEMS (Cheek all that apply) TRIENNIAL PIPING INTEORITY TEST (0.1 GPH) SAFE SUCTION SYSTEMS (NO VAL ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM [37. SELF MONITORING IN BELOW GROUND PIPING): 06. TRIENNIAL INTEGRITY TEST (0. I GPH) GRAVITY FLOW SAFE SUCTION SYSTEMS (NO VALVES IN BELOW GROUND PIPING): ❑ 9. BIENNIAL INTEGRITY TEST (0 I GPH) 07. SELF MONITORING GRAVITY FLOW (Check all that apply): 09. DAILY VISUAL MONITORING SECONDARILY CONTAINED PIPING ❑ 9. BIENNIAL INTEGRITY TEST (0.1 GPH) / PRESSURIZED PIPING (Check all that ,!J ply): ✓✓ ' / SECONDARILY CONTAINED PIPING / 10. CONTINUOUS TURBINE SUM ALARMS AND (Check one) SENSOR W PRESSURIZED PIPING (Check all that apply): i AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR ❑ a. AUTO PUMP SHUT OFF W WITH AUDIBLE AND VISUAL HEN A LEAK OCCURS ALARMS AND (Check oro) ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE AND SYSTEM 0 a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS DISCONNECTION ❑ b. AUTO PUMP SHUT OFF FOR LEAKS, SYSTEM FAILURE 0e. NO AUTO PUMPSHUTOF AND SYSTEM DISCONNECTION ❑ 11. AUTOMATIC LINE LEAK D OR (3.0 GPH TEST) WITH FLOW SHUT Oc. NO AUTO PUMP SHUT OFF OFF OR RESTRICTION 0 11. AUTOMATIC LEAK DETECTOR 0 12. ANNUAL INTEGRITY TEST (0.1 PH) SUCTION/GRAVITY SYSTEM ❑ 12. ANNUAL INTEGRITY TEST (0.1 GPH) ❑ 13. CONTINUOUS SUMP 'SENSOR + SUCTION/GRAVITY SYSTEM UDIBLE AND VISUAL ALARMS GENERATORS ONLY ((heck ❑ CONTINUOUS SUMP SENSOR + AUDIBLE AND VISUAL ALARMSEMERGENCY all that apply) 014. CONTINUOUS SUSORMP AND VISUALALA EMERGENCY GENERATORS ONLY (Check all that apply) AUTO PUMP SHUT OFFAUDIBLE O 14. CONTINUOUS SUMP SENSOR ❑ 15. AUTOMATIC LINE LEAK D iQUSAUTO PUMP SHOT OFF CTOR( 3.0 GPH TES AUDIBLE AND VISUAL ALARMS T)� FLOW SHUT OFF OR RESTRICTION ❑ 16. ❑ 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) ANNUAL PH) VISUAEGRITY L ❑ 17, DAILY VISUAL CHECK ❑ 16. ANNUAL INTEGRITY TEST (0. I GPH) 0 17. DAILY VISUAL CHECK DISPENSER CONTAINMENT 46a. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE DATEINSTAL 4. DAILY VISUAL CHECK 469. ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WAUTO SHUT OFF FOR 115, 5 �NCH/LINER MONITORING ITH DISPENSER+AUDIBLE AND VISUAL ALARMS. NONE I certify that the information provided h aW. 13i4 1�StNA1[lR� rein is SIGNATURE OFO ER/OPERATOR true and accurate to the best of my knowledge. DATE: 470. use use only) 495. UPCF hwfwrc-6 (1/99) - 3/4 http://www.unido,,org Rev. 02/16/00