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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 VI.PIPING CONSTRUCTION(Check an trat appy) UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTIOW ❑ 1. SINGLE WALL ❑ 3. UNEDTRENCH ❑W. OTHER ❑ 1. SINGLE WALL 1195. UNKNOWN MANUFACTURER ❑ 2. DOUBLE WALL 1195. UNKNOWN ❑ 2. DOUBLE WALL 1199.OTHER MANUFACTURER MANUFACTURER ❑ 1.SARE STEEL ❑ 8. FRP COMPATIBLE W/10D%METHANOL ❑ 1. BARE STEEL ❑ S.FRP COMPATIBLE WI 1W%METHANOL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7.GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTICCOMPATIBLENITHCONTENTS 095. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ S.FLEABLE(HDPE) 1199. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) 1199. OTHER ❑ 4. FIBERGLASS ❑ 9.CATHODIC PROTECTION ❑ S. STEELW/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. SMELWICOATING ❑95. UNKNOWN VIL PIPING LEAK DETECTION(CMck aB that apply) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WA_LPIPING PRESSURIZED PIPING(Check a9f at apply: PRESSURIZED PIPING(Ch a9ltat appy): - ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC UNE LEAK DETECTOR 3.0 GPM TEST WITH 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. 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: CONVENTIONAL SUCTION SYSTEMS(Check 0that apply): ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING INTEGRITY ❑ S. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST IDA GPM) ❑ 8.TRIENNIAL INTEGRITY TEST(0.1 GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑ 7.SELF MONITORING ❑ T.SELF MONITORING - GRAVITY FLOW. GRAVITY FLOW(Check ell Nat appy): ❑ 9. BIENNIAL INTEGRITY TEST IDA GPM) ❑ S. DAILY VISUAL MONITORING ❑ 9. BIENNIALINTEGRITY MST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Cmck a9 that appy): PRESSURIZED PIPING(C)axG a8 that apply: 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND (CheG one) 10.CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(heck one) ❑ a. AUTO PUMP SHUT OFFWNEN A LEAKOCCURS ❑ e.AUTO PUMP SHUTOFFWIENA LEAKOCCURS ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑ b.AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION ❑c NOAUTO PUMP SHUT OFF ❑ c NOAUTOPUMPSHUTOFF ❑ 11.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTCW%TIC LEAK OETECTOR RESTRICTION ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 12.ANNUAL INTEGRITY MST(0.1 GPM) BUCTIONIGRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR-AUDIBLE AND VISUAL ALARMS ❑ 13.CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Crack a9 that appy) EMERGENCY GENERATORS ONLY(CMck 0 that app/A 014.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14.CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15.AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ 18.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DMLYVISUALCHECK ❑ 17. DAILY VISUAL CHECK VOL DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SMEAR VALVE ❑ 4. DAILYVISUALCHECK DATE INSTALLED ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 5.TRENCH LINER/MONITORING ❑ 3.CONTINUOUS DISPENSER PAN SENSOR NTH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS ❑ 9. NONE IX OWNER/OPERATOR SIGNATURE I CBNy Mal the inrplmation pra ided harem la bre and a..ta W IM beat at my kmWixige. SIGNATUREOFOWMER/OPERATOR PATE NAME OFOWNER/OPERATOR(pdny TRE OF OWNEMOPERATOR PermB Number(Forlocal a only) Parma APPreved(Forlocal use or 4l Permit E piretion Data(Forth l use only) CUPAFORM(4/99) Formedy SWRC13 Form B