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Got. 23 66 12: 12p owner 209*1 -0142 p. ? <br /> kp- <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS- TANK PAGE 2 <br /> Pae of <br /> VI.PIPINGCONSTRUCTION(clmkatl <br /> UNDERGROUND PIPING I ABOVEGROUND PIPING <br /> SYSTEM TYPE 0 I.PRESSURE [12.SUCTION 0 3.GRAVITY 458. 0 I.PRESSURE ❑2.SUCTION [13.GRAVITY 459. <br /> CONSTRUCTIGN/ 0 <br /> 1.SINGLE WALL 03.LINED TRENCH 099.OTHER 40. 01.SINGLE WALL 095.13NKNOWN 462 <br /> MANCFA( MR 2.DOUBLE WALL [195.UNKNOWN ❑7 DOUBLE WALL [199,OTHER <br /> MANUFACTURER 461. MANUFACTURER 461 <br /> ❑1.BARE STEEL 06.FRP COMPATIBLE W/100%METHANOL El 1.BARE STEEL 06.PRP CONE PATIBLE W/1MIA MFFFe-OL <br /> IL 2.STAINLESS STEEL 0 7.GALVANIZED STEEL 0 2.STAINLESS STEEL 0 7.GALVANIZED SMEL <br /> 03.PLASTIC COMPATIBLE WITH CONTENTS 095.UNKNOWN 03.PLASTIC COMPATIBLE W/CONT'ENIS 06.FMIBLE(HDPE) 099.OTHER <br /> F(I 4.FIBERGLASS 0 8.FLEXIBLE(HOPE) 0 99.OTHER 0 4.FIBERGLASS 0 9.CATHODIC PROTECTION <br /> ❑5.STEEL W/COATING 0 9.CATHODIC PROTECTION 464. 0 S.STEEL W;COATING 0 95.UNKNOWN :55. <br /> VII.PIPING LEAK DETECTIONCbskaO Vet (Adao ofae m9mlo' am sba0 b:submlW loNeja9 <br /> UNDERGROUND PIPING ABOVEGROUND P11 <br /> SINGLE WALL PIPING 4% SINGLE WALL.PIPING 467. <br /> PP.ESSL'RIZED PIPING(Chock 0 Qat.ppb,,): PRESSURIZED PIPING(Check aI Ibat apply): <br /> 01. ELECTRONIC LME LEAK DETECTOR 3.0 GPH TEST Yj UH AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> SHUT-OFF-FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SRUT CFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. <br /> [12. MONIALY 02 GPH TEST 0 2. MONTHLY 0.2 GPH TEST <br /> 03. ANNUAL INTEGRITY TEST(0J GPH) 03. ANNUALINTEGRITYTEST(DAGPH) <br /> 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check aR Out apply) <br /> E15. DAILY VISUAL MONITORIING OF PUMPNG SYSTEM+'TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING ANO PUMPNG SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): E]6. TRIENNIAL INTEGRITY TEST(0-1GPH) <br /> 07. SELFMONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELFMONITORING <br /> 09. BIENNIALINTEGRITYTEST(O.IGPS) CRAVITYFLOW(Cbeckallthatapply): <br /> Els. DAILY VISUAL MONITORING <br /> [39, BIENDIAL 1NTEGR7TY TEST(O.I GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Clock all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR W TH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> 0 a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 0. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE A.\•O SYSTEM 0 b.ALTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> 0c. NO AUTO PUMP SHUT OFF 0c, NO AUTO PUMP SHUTOFF <br /> ❑11. AUTOMATIC.LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT <br /> OFF OR RESTRICTION II AUTOMATIC LEAK DETECTOR <br /> 0 <br /> 0 12. ANNUAL IN.EGRTIY TEST(0.1 GPH) ❑12.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS Gla.CONTINUOUS SUMP SENSOR+AUDIBLE ANDVISUALALARMS <br /> EMERGENCY GENERATORSONLY(Checkalldntnpply) EMERGENCY GENERATORS ONLY(Chmk al that apply) <br /> 014. CONTNUOUS SUMP SENSORWTIHOITC AUTOPUMPSHUTOFF 014.CONIINUOUSSUMP SENSOR WrrHOfff AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 015. AUTOMATIC LINE LEAK DETECTOR(E0 GPH TEST) WITHOUT FLOW <br /> SHUT OFF OR RESTRICTION [115.AUTOMATIC LINE LEAK DETECTOR(3.D GPH TEST) <br /> ❑16. ANNUAL IN TEST(0.1 GPH) [136.ANNUAL NTEGRITY TEST(0.1 GPH) <br /> 017. DAILY VISUAL CHECK [117.DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINIMNT <br /> DISPENSER CONTAINMENT 468. 71. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑4. OAILYVISUALCHECK 469 <br /> DATEINST.SLLED i 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 05. TRENCH/LINER MONITORING <br /> Jt3. CONTINUOUS DISPENSER PAN SENSOR xmi AUTO SHUT OFF FOR 06. NONE <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> TX:OWNERJOPERATOR SIGNATURE <br /> I certify that the infomtation pro hOccumte to the best of my knowledge. <br /> SIGNATURE OF ER'OPP O DATE: Opo. <br /> /o : O� <br /> NAME OF OWN OPERATO L ) TITLE OF 03 , E 6PFRflfOR: 4m <br /> Pcra•tNumbcr(Agencyunamly) 473. 1 Penult ApprovWRY(Agncyosconly) 474 1 Pettml Eimintion Dae(Agncyu40 only) 475. <br /> UPCF hwfwm-h(I/M-314 llttp W..-,.unidoeb.org Rev.02116/08 <br />