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M) it�MA �o-zw-ems Oied Program Consolidated ForrW TANKS UNDERGROUND STORAGE TANKS -TANKS PAGE 2 Page_of V1.PIPING CONSTRU TION (Check all that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE E]2.SUCTION [:13.GRAVITY 456 01.PRESSURE 2.SUCTION 3.GRAVITY 459 [:]1 SINGLE WALL E]3.LINED TRENCHE]99.OTHER 460 1:11 SINGLE WALL []95.UNKNOWN 462 CONSTRUCTION/ [:]2,DOUBLE WALL []95.UNKNOWN []2.DOUBLE WALL 099.OTHER MANUFACTURER MANUFACTURER 461 llr''"""��l MANUFACTURER 463 MATERIALS AND X®2,SINGLE WALL DOUBLE WALL �7.GALVANIZED STEELFIRP COMPATIBLE /100%METHANOL H2.STA STAINLESS STEEL ®7.GALVANIZED STEELE STEEL 6.FRP COMPATIBLE /100%METNANOL CORROSION M3.PLASTIC COMPATIBLE WITH CONTENTS [:]95.UNKNOWN E]3.PLASTIC COMPATIBLE WITH CONTENTS ❑8.FLEXIBLE(HDPE) PROTECTION E:]4.FIBERGLASS [:]8.FLEXIBLE(HDPE) [:]99.OTHER E]4.FIBERGLASS ❑9.CATHODIC PROTECTION [:]5.STEEL WICOATING 09.CATHODIC PROTECTION 464 115.STEEL W/COATING 095.UNKNOWN 465 ,,,, VII. PIPING LEAK DETECTION UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ri1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO SHUT OFF FOR 1.ELECTRONIC LIEN LEAK DETECTOR 3.0 pH TEST WITH AUTO PUMP SHUT OFF FOR LEAK LEAK SYSTEM FAILURE,AND SYSTEM DISCONNECTION*AUDIBLE AND VISUAL SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ALARMS. E2.,MUN I BUY U2 GPH I ES I M2.MONTHLY 02 HPG TEST 03.ANNUAL INTEGRITY TEST(0.1 GPH) ❑3.ANNUAL INTEGRITY TEST(0.1 GPH) 114.OAILV VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: FJS.DAILY VISUAL MONITORING OF PUMPING SYSTEM-TRIENNIAL PIPING INTEGRITY CONVENTIONAL SUCTION SYSTEMS(Check all that apply): I ES I III GPH) F-1 b.DAILY VISUAL MUNI I URINE OF PIPINU AND PUMPINU SYS I EM SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [:]7.SELF MONITORING E]6.TRIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW: SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): Me.BIENNIAL INTEGRITY TEST(0.1 GPH) []7.SELF MONITORING GRAVITY FLOW(Check all that apply): 118.DAILY VISUAL MONITORING 1:19.BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZE PIPING lCheck all that supply): PRESSURIZED PIPING(Check all that apply) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check ®1U.UUN I INUVUS I UR6INL SUMP SENSOR WI I H AUUIBLE AND VISUAL ALARMS AND one) (Check one) ❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS X❑a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS. E]bAUTO PUMP SHUT OFF FOR LEAKS,SVSTEM FAILURE AND SYSTEM DISCONNECTION ❑b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION Eli NO AUTO PUMP SHUT OFF WHEN A LEAK OCCURS. no.NO AUTO PUMP SHUT OFF 11.AUTOMATIC LEAK DETECTOR �11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT OFF OR RESTRICTION. ❑12.ANNUAL INTEGRITY TEST(0.1 GPM) 1-112.ANNUAL INTEGRITY TEST(0.1 GPH) SUMOWGRAVTTY SYSTEM: SUCTION/GRAVITY SYSTEM: Ej13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS E]13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Cheek all Mat apply) EMERGENCY GENERATORS ONLY(Cheek all Mat apply) �14.1:UN I INUVUS SUMP SENSOR W I I HUD I FLOW SHU I UFF UK 14.CVNIINUUUS SUMP SENSOR WI I HUU I AU I U PUMP SHU I OF IF AUDIBLE AND VISUAL VISUAL ALARMS ALARMS �15.AU I UMA I IU LINE LEAK UE I EG I UK NIM GPH IES I)win I BUD IFLUW SHUI UFF UK 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) rli6.ANNUAL INTEGRITY TEST(0.1 GPH) 16.ANNUAL INTEGRITY TEST(0.1 GPH) 1311.UAILY VISUAL CHECK if,UAILY VISUAL CHEUK ow-W-1 " VIIf.DISPENSER CONTAINMENT DISPENSER CONTAINMENT F-11.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE E]4.DAILYVISUALCHECK DATEINSTALLED 468 O2.CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS 5.TRENCH LINERIMONITORING Ob.CUNIINUVUSUISPENSBRPANSENSOR VVI INAN10 TUIOFF FUR UISYENSEH-AUDIBLE ANUVISUAL ALARMS 6 NONE 469 XI:OWNERIOPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowlecge- 70 SIGNATURE OF OWNEWOPERATOR DATE 4 NAME OF OWNER/OPERATOR(prki 471 TITLE OF OWNER/OPERATOR 472 Kenneth M.Phillips Manager,Loss Control, Repairs and Maintenance Permit Nurneder peortocaluse only) 473 Pi Approved(Morkical use only) 474 Permit iration Date( or Ideal use only) 475 UPCF(199) Formerly SW RCB Form B