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D PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pa e2of2 VI.PIPING CONSTRUCTION(Check alkhata I UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ®1.PRESSURE D 2.SUCTION D 3.GRAVITY 458. D 1.PRESSURE D 2.SUCTION D 3.GRAVITY 459. CONSTRUCTION/ D 1.SINGLE WALL D 3.LINED TRENCH D 99.OTHER 460. D 1.SINGLE WALL D 95.UNKNOWN 462. MANUFACTURER ®2 DOUBLE WALL D 95.UNKNOWN D 2.DOUBLE WALL D 99.OTHER MANUFACTURER A.O. SMITH 461. MANUFACTURER 463. D 1.BARE STEEL D 6.FRP COMPATIBLE W/100%METHANOL [11.BARE STEEL D 6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL [17.GALVANIZED STEEL D 2.STAINLESS STEEL [17.GALVANIZED STEEL ❑3.PLASTIC COMPATIBLE WITH CONTENTS [195.UNKNOWN D 3.PLASTIC COMPATIBLE W/CONTENTS D 8.FLEXIBLE(HDPE) D 99.OTHER ®4.FIBERGLASS [18.FLEXIBLE(HDPE) D 99.OTHER [:14.FIBERGLASS [19.CATHODIC PROTECTION ❑ S.STEEL W/COATING [19.CATHODIC PROTECTION 464, [15.STEEL W/COATING D 95.UNKNOWN 465. VIL PIPING LEAK DETECTION Chmkallthat I Adascntionorthe rueelttkin rogam shall subnitedto the local aac. UNDERGROUND PIPING t ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 011. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WIT B AUTO PUMP [11. 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. [12. MONTHLY 0.2 GPH TEST [12. MONTHLY 0.2 GPH TEST 5. ANNUAL INTEGRITY TEST(0.1 GPH) D 3. ANNUAL INTEGRITY TEST(0.1 GPH) D 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS CONVENTIONAL SUCTION SYSTEMS(Check all that apply) D 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING D 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): [16. TRIENNIAL INTEGRITY TEST(0.1 GPH) [17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW [17. SELF MONITORING [19, BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [18. DAILY VISUAL MONITORING [19. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WIT 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 D a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ®b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM D b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION Dc. NO AUTO PUMP SHUT OFF Dc. NO AUTO PUMP SHUT OFF ® 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLOW SHUT D 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION D 12. ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM D 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS [113. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) D 14. 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 D 15. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW D 15. 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) D 17. DAILY VISUAL CHECK D 17. DAILY VISUAL CHECK Vlll.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. [11. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 04. DAILY VISUAL CHECK 469. DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS D 5. TRENCH/LINER MONITORING 1999 ®3. CONTINUOUS DISPENSER PAN SENSOR WIT AUTO SHUT OFF FOR D 6. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS IX.OWNER/OPERATOR SIGNATURE I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF OWNER/OPERATOR I DATE: 610. NAME OF OWNERIOPERATOR(print: TITLE OF OWNER/OPERATOR: 472. otSs�6Jry ,714141-1 /2;91Hi ow.v Pemtit Nwnber(Agency use only) 473 1 Permit Approved By(Agency use only) 474. 1 Permit Expiration Date(Agency use only) 48. UPCF hwfwrc-b(1/99)-3/4 hftp://www.unidocs.org Rev.02/16/00