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NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(CMck aI mat appy) UNDERGROUND,PIPING ABOV EGRCLYD aiPNG SYSTEMTYPE ❑ 1 PRESSURE X., SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTION) ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ,❑ 2. DOUBLE WALL )545. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER 1.BARE STEEL ❑ 9. FRP COMPATIBLE WI 100%METHANOL ❑ 1. BARE STEEL ❑ B. FRP COMPATIBLE W/100%METHANOL MATERIALS AND r,. STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSIONPROTECTION 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS 118. FLEXIBLE(HOPE) - ❑99. OTHER 4. FIBERGLASS ❑ 9. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION 5. STEELWICOATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEELW/COATING El 95, UNKNOWN VII:PIPING LEAK DETECTION(Check all that appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check ak that apply. PRESSURIZED PIPING(Chxk ell tMt apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST NTH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST NTH 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 0.2 GPM TEST ❑ 2. MONTHLYG ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) 13 3.ANNUAL INTETEGRITYITY TEST(0.1 GPM) ❑ 4, DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS: CONVENTIONAL SUCTION SYSTEMS(Clack aN Met apply: ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST(0.1 GPM) ❑ e. TRIENNIAL INTEGRITY TEST IDA GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ T. SELF MONITORING ❑ T. SELF MONITORING GRAVITY FLOW GRAVITY FLOW(Clack all thefappy/: ❑ 9. BIENNIAL INTEGRITY TEST(0 1 GPM) ❑ e. 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 as that appy): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (Check ora) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(rAe&anal ❑ e. AUTO PUMP SHUT OFF MEN A LEAK OCCURS ❑ a.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ b, AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DIS ❑ <. NO AUTO PUMP SHUT OFF ❑ b, NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ RESTRICTION 11, AUTOMATIC LEAK DETECTOR ❑ 12. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12. ANNUAL INTEGRITY TEST 10.1 GPH) SUCTIONIGRAVITV SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR AUDIBLE AND VISUALALARMS EMERGENCY GENERATORS ONLY(Ohni aN that apply/ EMERGENCY GENERATORS ONLY(Check aI Met apply) ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF•AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHAT OFF•AUDIBLE AND,VISUAL VISUALALARMS ALARMS ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 15. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18.ANNUAL INTEGRITY TEST IDA GPM) ❑ 17. DAILY VISUAL CHECK ❑ 17. DAILY VISUAL CHECK VHL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATEINSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR•AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH UNER/MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER•AUDIBLE AND VISUAL ALARMS e. NONE IX.OWNER/OPERATOR SIGNATURE I iumi that Na Information provided hemi,is true and avurats to Me beet of my undated, SIGNATUREOFOWNERIOPERATOR DATE NAME OF OWNEWOPERATOR(pd,0 TITLE OF OWNMOPERATOR Peen,Number(Forlo<al use only) Permit Approved(Fw local bee only, Farrar Expiration Date(Forlacel use only) CUPAFORM(4/99) Formerly SVVRCS Form B