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a U1 D PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 nf VI.PIPING CONSTRUCTION(Chack aP that appty) ABOVEGROUND PIPING UNDERGROUND PIPING ❑ 2. SUCTION ❑ 3_ GRAVITY ❑ 1. PRESSURE ❑ 3. GRAVITY ❑ 1. PRESSURE ❑95. UNKNOWN SYSTEM TYPE . SUCTION ❑99. OTHER ❑ i. SINGLE WALL ❑99. OTHER CONSTRUCTIOW ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑ 2 DOUBLE WALL MANUFACTURER [12. DOUBLE WALL ❑95. UNKNOWN MANUFACTURER MANUFACTURER ❑ 8. FRP COMPATIBLE W/100%METHANOL ❑ 1.BARE STEEL ❑ 0. FRP COMPATIBLE WI 100%METHANOL ❑ 2 BARINLESS ❑ T GALVANIZED STEEL MATERIALS AND ❑ 2. STAINLESS STEEL ❑ ]. GALVANIZED STEEL ❑ 2.STAINLESS STEEL ❑99. OTHER 5. UNKNOWN ❑ 3. FIBERGLASS COMPATIBLE WITH CONTENTS B. FLEXIBLE(HDPE) CORROSION ❑ 3. PLASTIC COMPATIBLEWITH CONTENTS ❑ 9. CATHODIC PROTECTION PROTECTION ❑ 4. FIBERGLASS ❑ 4. FIBERGLASS ❑ 0. FLEXIBLEMOPE) ❑99. OTHER ❑ 5. STEEL W/COATING 95 UNKNOWN UNKNOWN ❑ 5. STEEL WI COATING ❑ 9. CATHODIC PROTECTION NI.PIPING LEAK DETECTION(Chock aN$net appy) ABOVEGROUND PIPIrvG UNDERGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING INE(ChLE all that DETECTOR PRESSURIZED PIPING(Check ay"al epPyk ❑ 1. ELECTRONIC UNE LEAK DETECTOR J 0 GPM TEST WITH AUTO PUMP SHUT OFF FOR LEAK, "VATH AUTO PUMP SHUT SYSTEM FAILURE,AND SYSTEM DISCONNECTION+AUDIBLE AND VISUAL ALARMS ❑ 1 LEAK,SYYSTIEM FAILURE.ANC LINE LEAK D SYSTEM DISCONNECTION+AUDIBLE ANO VISUAL SYSTEM ❑ 2. MONTHLY 02 GPM TEST ALARMS ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 2. MONTHLY 0.2 GPH TEST 4. DAILY VISUAL CHECK ❑ 3.ANNUAL INTEGRITY TEST(DA GPM) ❑ CONVENTIONAL SUCTION SYSTEMS(GMCk all that apply: CONVENTIONAL SUCTION SYSTEMS'. ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM ❑ 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY ❑ 5 TRIENNIAL INTEGRITY TEST(0A GPM) TEST(0.1 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(Check all that appM: GRAVITY FLOW: ❑ e. DAILY VISUAL MONITORING ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ 9. BIENNIALINTEGRItt TEST(0.1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that epPyJ: PRESSURIZED PIPING(Check all that apply): 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10,CONTINUOUS TURBINE SUMP SENSOR`MTH AUDIBLE AND VISUAL ALARMS AND(check one (Check one) ❑ e.AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ e. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑ B AUTDISCO PUMP SHUTION OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑ c. NOAUTO PUMP PUMPUHOTFFOR LEAKS.SYSTEM FAILURE AND SYSTEM DISCONNECTION OFF ❑ c. NOAUTO PUMP SHUT OFF ❑ 11 AUTOMATIC UTO ATIC LINE LEAK DETECTOR @.0 GPH TEST)WITH FLOW SHUT OFF OR [j 11 ANNUAL INTEGRITY DETECTOR TELT(0.1 GPM) REST ❑ 12.ANNUAL INTEGRITY TEST(0 1 GPM) SUCTION/GRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM: ❑ 13, CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check aN that appy) EMERGENCY GENERATORS ONLY(Check aN that epply) ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF-AUDIBLE AND ❑ 14.AANRLIIN50U5 SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUALAURMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC UNE LEAK OETECT00.O.0 GPM TEST) RESTRICTION ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17, DAILY VISUAL CHECK ❑ 1T. DAILY VISUAL CHECK - VNL DISPENSER CONTAINMENT ❑ 4. DAILY VISUAL CHECK DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 5. TRENCH LINER I MONITORING DATEI STA 0 ❑ 2. CONTINUOUS DISPENSER PAN SENSOR AUDIBLE AND VISUAL ALARMS ❑ 3, CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS NE OWNER/OPERATOR SIGNATURE I cattily Net Ne inlonnawn provided herein to true and acwrate to Ne Deet 0 my kraaleC9e. DATE SIGNATURE OF OWNERIOPERATOR TITLE OF OWNENOPERATOR NAME OF OWNER/OPERATOft(prtnp Pemht ExpimOon Data(Fprlecal use Omy) Permit Numtx((FOrbcel use only) Permit AppmvaE(Fwlocal uw oMY) . • Formerly SWRCS Form B CUPAFORM(4/99)