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FIED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 A.PIPING CONSTRUCTION(ChackeeflietaPPIO UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE Cl 1. PRESSURE Cl 2. SUCTION Cl 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION/ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑W. UNKNOWN MANUFACTURER ❑ 2, DOUBLE WALL ❑W. UNKNOWN ❑ 2. DOUBLE WALL Cl W. OTHER MANUFACTURER Ul.sgt {&� MANUFACTURER I.BARE STEEL ❑ 6. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ 6. FRPCOMPATBLEVV 1W%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ 1. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 13 95. UNKNOWN [33. PLASTIC COMPATIBLE WITH CONTENTS Cl 8. FlE%IBLE(HDPE) 099. OTHER Cl 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WI COATNG ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL WI COATING Cl 95. UNKNOWN VII:PIPING LEAK DETECTION(C/Iack ae marappW UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check aN that apply): PRESSURIZED PIPING(Cmi aY net appy: ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WRH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST`HT1 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 ❑ 2, MONTHLY 02 GPM TEST ❑ 2. MONTHLY 0.2 GPH TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) Cl 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Cheek se Mat appy: ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ S. TRIENNIAL INTEGRITY MST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN SELOW GROUND PIPING): ❑ T. SELF MONITORING ❑ Z SELF MONITORING GRAVITY FLOW. GRAVITY FLOW(Check W that appy: ❑ 9. BIENNIAL INTEGRITYTEST IDA GPM) ❑ 8. DAILY VISUAL MONITORING ❑ 9. BIENNIALINTEGRITYTEST(OAGPN) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check ak that apply: PRESSURIZED PIPING(Clack aN that appy: 10. CONTINUOUS TURBINE SUMP SENSOR'NTH AUDIBLE AND VISUALALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Rlack ane) (Cheri ane) Cl a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ a. AUTO PUMP SHUT OFF MEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c NO AUTO PUMP SHUT OFF ❑ G NO AUTO PUMP SMUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11. AUTOMATICLEAKDETECTOR RESTRICTION ❑ 12 ANNUAL INTEGRITY TEST(0A GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) SUCTIONIGRAVITY SYSTEM: SUCTIONGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR I AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that appy EMERGENCY GENERATORS ONLY(Check aY that appy ❑ 14. CONTINUOUS SUMP SENSOR WTHOUT AUTO PUMP SHUT OFF-AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15.AUTOMATG LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 16. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DAILYVISUALCHECK ❑ 17. DAILY VISUAL CHECK VUL DISPENSERCONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILYVISUAL CHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR.AUDIBLE AND VISUAL ALARMS ❑ 5. TRENCH LINER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUALALARMS ❑ S. NONE IX.OWNERIOPERATOR SIGNATURE I rally Mat Me Intonation PNviEeol herein is=a all xarate to Ne best of my Mcni ledge. SIGNATURE OF OWNER/OPERATOR DATE NAME OF ONMERIOPERATOR(pant) TITLE OF OWNERIOPERATOR Perron Number(For local use onW Pemol AppmveE(Forlooal use Dory) Permit Stone.Date(Pw Iaoal useonly) CUPAFORM(4199) • • Formerly SVVRCB Form B