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ii g?"PROGRAM (YINRnLIIIATRD F0l`.' <br /> TANKS \Qy <br /> UNDERGROUND STORAGE TANKS -TANK PAGE 2 \9\91, <br /> Page of <br /> VI.PIPING CONSTRUCTION(check au naaapply) <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SYSTEM TYPE ®1.PRESSURE C 2.SUCTION C 3.GRAVITY 458, C L PRESSURE C 2.SUCTION C 3.GRAVITY 459. <br /> CONSTRUCTION/ 0 1.SINGLE WALL C 3.LINED TRENCH C 99.OTHER 460. C 1.SINGLE WALL C 95.UNKNOWN 462 <br /> MANUFACTURER ®2 DOUBLE WALL C 95.UNKNOWN C 2.DOUBLE WALL C 99.OTHER <br /> MANUFACTURER Smith FibercaSt 461, MANUFACTURER 463. <br /> [:11,BARE STEEL ®6.FRP COMPATIBLE W/100%METHANOL [11.BARE STEEL C 6.FRP COMPATIBLE W/100%METHANOL <br /> C 2.STAINLESS STEEL [17.GALVANIZED STEEL C 2.STAINLESS STEEL [17.GALVANIZED STEEL <br /> C 3.PLASTIC COMPATIBLE WITH CONTENTS C 95.UNKNOWN C 3.PLASTIC COMPATIBLE W/CONTENTS C 8.FLEXIBLE(HDPE) C 99.OTHER <br /> [14.FIBERGLASS C 8.FLEXIBLE(HDPE) [199,OTHER C 4.FIBERGLASS C 9.CATHODIC PROTECTION <br /> ❑5.STEEL W/COATING C 9.CATHODIC PROTECTION 464. C 5.STEEL W/COATING C 95.UNKNOWN 465. <br /> VR.PIPING LEAK DETECTION(check all that 1)(A deamiption ofthe monnsfing pno,oun shill be subminul to the local agm <br /> UNDERGROUND PIPING ABOVEGROUND PIPING <br /> SINGLE WALL PIPING 466. SINGLE WALL PIPING 467 <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP [11. 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 /> ❑2. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST <br /> 03. ANNUAL INTEGRITY TEST(0.1 GPH) [33. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> 04. DAILY VISUAL CHECK <br /> CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) <br /> [35. DAILY VISUAL MONITORING OF PUMPING SYSTEM,TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM <br /> INTEGRITY TEST(0.1 GPH) <br /> SAFE SUCTION SYSTEMS(NO VALVES M BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) <br /> C 7. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): <br /> GRAVITY FLOW [17. SELF MONITORING <br /> [19. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): <br /> [18. DAILY VISUAL MONITORING <br /> [19. BIENNIAL INTEGRITY TEST(0.1 GPH) <br /> SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING <br /> PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): <br /> 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL <br /> ALARMS AND(Check one) ALARMS AND(Check one) <br /> C a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS C a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS <br /> ®b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM C b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM <br /> DISCONNECTION DISCONNECTION <br /> Cc. NO AUTO PUMP SHUT OFF Cc. NO AUTO PUMP SHUT OFF <br /> ® <br /> 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT C 11 AUTOMATIC LEAK DETECTOR <br /> OFF OR RESTRICTION <br /> ❑12. ANNUAL INTEGRITY TEST EII GPH) C 12. ANNUAL INTEGRITY TEST(0.1 GPH) <br /> SUCTIONIGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM <br /> [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS C 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS <br /> EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) <br /> 014. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF C 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF <br /> AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS <br /> C 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW [115. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) <br /> SHUT OFF OR RESTRICTION <br /> C 16. ANNUAL INTEGRITY TEST(0.1 GPH) C 16.ANNUAL INTEGRITY TEST(0_I GPH) <br /> C 17. DAILY VISUAL CHECK C 17. DAILY VISUAL CHECK <br /> VIII.DISPENSER CONTAINMENT <br /> DISPENSER CONTAINMENT 46s. C L FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE C 4. DAILY VISUAL CHECK 469. <br /> DATE INSTALLED 02. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS C5. TRENCWLINERMONITORING <br /> 2006 ®3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16. NONE <br /> DISPENSER+AUDIBLE AND VISUAL ALARMS <br /> IX.OWNER/OPERATOR SIGNATURE <br /> ANAMEO <br /> e info i to ed herein is true and accurate to the best of my knowledge. <br /> OWNS TO DATE: / 470. <br /> OPERATOR(print): TITLE OF OWNER/OPERATOR: 073- <br /> Permit Number(Agency use only) 473 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use onl)) 475. <br /> UPCF hwfwrc-b(1/99)-3/4 http://www.unidoes.org Rev.02/16/00 <br />