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57301 UNIFIED PROGRAM CONSOLIDATED FORM YANK: PR0232573 PR#: PR0232573 AC#: FA0003941 UNDERGROUND STORAGE TANKS -TANK PAGE 2 VL PIPING CONSTRUCTION(check all trot apply) Pago 3 ora UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ L PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 458 ❑ I.PRESSURE ❑ 2.SUCTION ❑ 3.GRAVITY 459 CONSTRUCTION ❑1.SINGLE WALL ❑3.LINEDTRENCH ❑ 99.OTHER 460 ❑ L SINGLE WALL ❑ 95.UNKNOWN 462 ❑2.DOUBLE WALL F1 95.UNKNOWN 461 E:1 2,DOUBLE WALL El 99.OTHER 463 MANUFACTURER MANUFACTURER ❑ 1,BARE STEEL ❑6.FRP COMPATIBLEv/19095 METHANOL ❑ I_BARE STEEL ❑ 6.FRP COMPATIBLE W 100%METHANOL ❑ 2.STAINLESS STEEL ❑ 7.GALVANIZED STEEL ❑ 2.STAINLESS STEEL [I ].GALVANIZED STEEL F1 PLASTIC COMPATIBLE W/CONTENTS r-195.UNKNOWN E] PLASTIC COMPATIBLE W/CONTENTS ❑ 95.UNKNOWN ❑ 4.FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ ".OTHER ❑ 4_FIBERGLASS ❑ 8.FLEXIBLE(HDPE) ❑ 99.OTHER ❑ S.STEEL W/COATMG ❑ 9.CATHODIC PROTECTION 464 ❑ 5.STEEL W/COATING ❑9.CATHODIC PROTECTION 465 W.PIPING LEAK DETECTION Klock allthat apph)(A dacopm ofth:mooho^as pmerarn SMI h:snnmimd to the law a .I UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466 SINGLE WALL PIPING 467 PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): ❑ I.ELECTRONIC LINE LEAK DEFECTOR 3 0 GPM TEST WITH AUTO PUMP SHUT OFF ❑ 1.ELECTRONIC LINE LEAK DETECTOR 3 0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND FOR LEA SYSTEM FAILURE,AND SYSTEM DISCONNECTIOAUDIBLE AND AL VISUAL ALARMS. VISARMS ❑ 2.MONTHLY 0.2 GPM TEST ❑ 2.MONTHLY 0.2 GPM TEST ❑ 3.ANNUAL INTEGRITY TEST(0,1 GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4.DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check all that apply) CONVENTIONAL SUCTION SYSTEMS ❑ 5.DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIEAL PIPING INTEGRITY TEST(0.1 GPM) ❑ 6.TRIENNIAL INTEGRITY TEST(0.1 GPI) SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPI NG): SAFE SUCTION SYSTEMS(NO VALUES IN BELOW GROUNDPIPING): ❑ ].SELF MONITORING ❑ 7.SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Check all that apply): ❑ 9.BIENNIAL INTEGRITY TEST(0 1)GPM ❑ 8.DAILY VISUAL MONITORING ❑ 9.BIENNIAL INTEGRITY TEST(0.1)GPM SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): 10,CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10 ALARMSINOUST R INE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(Ch 1:one) ❑ e. [D 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 ❑ c.NO AUTO PUMP SHUT OFF ❑ c. NO AUTO PUMP SHUT OFF ❑ 11 AUTOMATIC LME LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ H AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) SUCTION/GRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Deck all them app).) EMERGENCY GENERATORS ONLY(Dark all that apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF' AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS ❑ 15.AUTOMATIC LME LEAK DETECTOR 0 0 GPM TEST)WITHOUT FLOW ❑ 15 SHUT OPF OR NIC LIKE LEAK DETECTOR(3 0 GPM TEST)WITHOUT FLOW SHUT OFF OR RESTRICTION ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM ❑ 16.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17.DALLY VISUALCHECK ❑ 1].DAILY VISUAL CHECK Vlll.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1.FLOAT MECHANISM THAT SHUTS OFF SMEAR VALVE ❑ 4.DAILY VISUAL CHECK DATE INSTALLED 468 ❑ 2.CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR ❑ 6.NONE DISPENSER+AUDIBLE AND VISUAL ALARMS 469 IX.OWNER/OPERATOR SIGNATURE I ocraA Inc the intommtion pmvidd heroin is to and nemrmcto the h:m ofmy knon%L gc SIGNATURE OF OWNER/OPERATOR DATE 479 NAME OF OWNER/OPERATOR(print) TITLE OF OWNER/OPERATOR 411 4]2 Permit Numb (For low usa only) 473 permit Appoon,d(I"low use onh) 474 Konno Epimtion Date(F.low use-10 475 PT0006879 EE0000817 12/31/2005 12:00:OOAM UPCF(12/99 revised)