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-0142 p. 9 <br /> 'Oct 23 06 12: 13p ow "" 2091 <br /> r UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS-TANK PAGE 2 <br /> Pae of <br /> V1.POlsltaxlauaapplPl <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM IYPE ❑1.PRESSURE C 2.SUCTION 0 3.GRAVITY 458, 0 L PRESSURE 0 2.SUCTION 01 GRAVITY 459. <br /> CONSTRUCTION! 01.SINGLE WALL 03.LINED TRENCH 099.OTHER 460. 01.SINGLE WALL 095.INKNOWN 462. <br /> MANUFACTURER 5(2.DOUBLE WALL 095.UNKNOWN 02.DOUBLE WALL ❑99.OTITER <br /> MANUFACTURER 461. I MANUFACTURER 463, <br /> OI.BARE STEEL 06.FRP COMPATIBLE WA00%METHANOL 01.BARE STEEL 06.FRP COMPATIBLE W1100%METHANOL <br /> 0 2.STAINLESS STEEL [17.GALVANIZED STEEL [12.STAINLESS STEEL [17.GALVANIZED STEEL <br /> 0 3.PLASTIC COMPATIBLE WITH CONTENTS 0 95.UNKNOWN 0 3.PLASTIC COMPATIBLE W/CONTENTS 0 8.FLEXIBLE(HDPE) 0 99.OTHER <br /> IR 4,FIBERGLASS 0 e.FLEXIBLE,(HDPB) []99.OTHER [14-FIBERGLASS C 9.CATHODIC PROTECTION <br /> 0 5.STEEL W/COATING 09.CATHODIC PROTECTION 464. ❑5.STEEL W20ATING 0 95.UNKNOWN 9G5. <br /> - VIL PIPING LEAK DETECTION CIAAld (A6un baofdc yank« ,ahall x.6nunl lathe bwa <br /> UNDERGROUND PIPING ABOVEGROUND i'IPMG <br /> SINGLE WALL PIPING 466. SINGLE WALL PIPING 967 <br /> PRESSURIZED PIPING(Cheek all that apply): PRESSURIZED PIPING(Check a0 0ntapp(y): <br /> 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP 01. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP <br /> SHUT-OFF FOR LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION <br /> +AUDIBLE AND VISUAL ALARMS- +AUDIBLE AND VISUAL ALARMS <br /> 02. MONTHLY0ZGPH TEST 02 MONTHLY 01 GPH TEST <br /> 03. ANNUAL INTEGRITY TEST(9.!GPH) 03. ANNUAL INTEGRITY TEST(10.t GPH) <br /> 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Cluckall tlutappty) <br /> E15. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING 05. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16, TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> 0 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW 07. SELFMONITORING <br /> 09. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Ct=kal lhotapply): <br /> 08. DAILY VISUAL MCNITORINO <br /> 0 9. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> It PRESSURIZED PIPING(Chcckall 0utapPly): PRESSURIZED PIPING(Check all datapply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AMD VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Clleck one) ALARMS AND(Check ota) <br /> 0 a_ AUTO PUMP SHUT OFF WHEN A LEAK OCCURS 0 a. ALTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> 0 b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM 0 b.AUTO PUMP SHUT OFF FOR LEAKS.SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> 0c. NO AUTO PUMP SHUT OFF 0c NO AUTO PUMP SHUT OFF <br /> CII, AUTOMATIC LINE LEAK DETECTOR 13.0 GPH TEST)W3`Cf FLOW SHUT 0 11 A.UTOMAIIC LEAK DETECTOR <br /> OFF OR RESTRICTION[112. ANNUAL INTEGRITY TEST(G.I GPH) 017 ANNUAL MTEGRITY TEST(0.1 GPH) <br /> SUCTION/GRAVITY SYSTEM SUCTIONIGRAVITY SYSTEM <br /> El 0. CONDNUOUSSUMP SENSOR+AUDIBLE AND VISUAL ALARMS 013.CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUALALAILMS <br /> EMERGENCY GENERA[OILS ONLY(Chcck 3:10ataPF:Y) EMERGENCY GENERATORS ONLY(Cbeck all.'hri <br /> 0 14. CONTINUOUS SUMP SENSOR WITHO AUTO PUMP SHUT OFF [114.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUTOFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> 015. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) WITHOUT FLOW 015.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> 016. ANNUALINTEGRITY TEST(0.1 GPH) 0 16.ANNUAL INTEGRITY TEST(0.1 GPH) <br /> [317- DAILY VISUAL CHECK 017.DAILY VISUAL CHECK <br /> VIII,DISPENSER CONTAINWNT- - <br /> OiSPENSERCONTAINMEN7 46t. fISL FLOAT MECHANISM THAT SHUTS OFF SHEAR VAL4E ❑4. DULY v1S1;AL CBGCK a6o, <br /> DATEINSTALLED LJ1 CONTINUOUS DISPENSER PAN SENSOR+AUDIBIEAND VISUAL.ALARMS 05. TRENCTULINER'MONUORI\G <br /> 5[3. CONUNUOUS DISPENSER PAN SENSOR WITH .AUTO SHUT OFF FOR 06. NONE <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> DT.OWNER/OPERATOR SIGNATURE <br /> Iccrtify that the information provided herein' a to the best ofmy knowledge. <br /> SIGNATURE OF OWNER/ TOR Z DATE: i70 <br /> NAMEOFOWNER,0PERATOR(print i nl�t-' ,S S �Ll TmJS OP ewePexxrex: v��/p'� <br /> Pannit Number(Agency use only) 4'n/1 Permit Aypmtxd SY(ABmeYuu aNY) 474. Pcmtit Eapimtion Dan,(Agency we only) 475. <br /> UPCF hwfwm.b(11")-3/4 http://www.unidoce.org Rev.02/16/00 <br />