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v w• !✓1 1 _fit Fn PRfIC]R AM CONRO T.In ATFO FOR TANKS �f "p UNDERGROUND STORAGE TANKS - TANK PAGE 2 0\1 P e of VI.PIPING CONSTRUCTION Icheck atmt l) UNDERGROUND PIPING I ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE ❑2.SUCTION ❑3.GRAVITY 458. [011 PRESSURE ❑2.SUCTION ❑3.GRAVITY 459. CONSTRUCTION/ 1.SINGLE WALL ❑3.LINED TRENCH ❑99.OTHER 460. ❑1.SINGLE WALL [195.UNKNOWN 462. MANUFACTURER ®2.DOUBLE WALL ❑95.UNKNOWN ❑2.DOUBLE WALL ❑99.OTHER MANUFACTURER Smith FibercaSt MANUFACTURER Qo ❑1.BARE STEEL ®6.FRP COMPATIBLE W/100%METHANOL ❑1.BARE STEEL 0 6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS [195.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑S.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS O S.FLEXIBLE(HDPE) [199,OTHER ❑4.FIBERGLASS [19.CATHODIC PROTECTION ❑ S.STEEL W/COATING [19.CATHODIC PROTECTION 464. ❑5.STEEL W/COATING ❑95.UNKNOWN 465. VR.PIPING LEAK DETECTION(Check a0 that )(A dmcriittion of the mnitonno prograrnshall be w1nninee to the local ) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP ❑1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS. 2. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST 03, ANNUAL INTEGRITY TEST(0.1 GPH) ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) [15. DAILY VISUAL MONITORING OF PUMPING SYSTEM,TRIENNIAL PIPING [15. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [36. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING [39. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): ❑S. DAILY VISUAL MONITORING [39, BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check ail that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a AUTO PUMP SHUT OFF WHEN 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 0c. NO AUTO PUMP SHUTOFF On. NO AUTO PUIv1P SHUT OFF ®11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT 11 AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION [112. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM 013. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF [114.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [315. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW [115, AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) [116. ANNUAL INTEGRITY TEST(0.1 GPH) ❑17. DAILY VISUAL CHECK [117. DAILY VISUAL CHECK VII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 469. ❑1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE [14. DAILY VISUAL CHECK 469. DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR,AUDIBLE AND VISUAL ALARMS ❑5. TRENCH/LINER MONITORING ZOOG ®3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR 0 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS It DL OWNER/OPERATOR SIGNATURE I cert the in( a p ided herein is true and accurate to the best of my knowledge. SIGN F O RA R PATE; 470' NAME OF O R/OPERATOR(prin TITLE OF O R/O ERATOR: 472 Permit Number(Agency use only) 473 1 Permit Approved By(Agency use only) 474. Permit Expiation Date(Agency use only) 475. UPCF hwfwre-b(1/99)-3/4 http://www.unidocs.org Rev.02/16/00