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4 UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 N.PIPING CONSTRUCTION(Check 0thef appy) ABOVEGROUND PIPING ' UNDERGROUND PIPING SYSTEM TYPE SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ L PRESSURE 1. SINGLE WALL ❑ 3. LINEDTRENCH ❑99. OTHER ❑ 1. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2. DOUBLE WALL ❑09. OTHER MANUFACTURER ❑ 2. DOUBLE WALL ❑95. UNKNOWN MANUFACTURER MANUFACTURER 1.BARE STEEL ❑ e. FRP COMPATIBLE W/100%METHANOL ❑ 1. BARE STEEL ❑ e. FRP COMPATIBLE WI100%METHANOL MATERIALS AND 2. STAINLESS GTEEL ❑ T.GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ T. GALVANIZED STEEL CORROSION ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑95. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HDPE) ❑99. OTHER PROTECTION ❑ B. CATHODIC PROTECTION 114. FIBERGLASS ❑ B. FLEXIBLE(HDPE) ❑99. OTHER ❑ 4. FIBERGLASS ❑ 5. STEEL WI COATING ❑ S. CATHODIC PROTECTION ❑ 5. STEEL W/COAING ❑95. UNKNOWN NI.PIPING LEAK DETECTION fUwsall Mat appy) ABOVEGROUND PIPING UNDERGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check ed Met apply)' PRESSURIZED PIPING(CAeck elf that appy): PUMP SHUT OFF ❑ 1. ELECTRONIC LINE LEAK DETECTOR 30 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ i SYSTEMOFAILURE.AND SYSTEM DISCONNECTION NIC LINE LEAK DETECTOR 3o GPM TEST=AUDSLE0R LEAK, AND ALARMS LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION•AUDIBLE AND VISUAL ALARMS ❑ 2 MONTHLY 0.2 GPM TEST ❑ 2. MONTHLY02GPH TEST ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3.ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS(Check aft that apply): ONVENTIONAL SUCTION SYSTEMS: ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM•TRIENNIAL PIPING INTEGRITY ❑ S. TRIENNIAL INTEGRITY TEST(0.1 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 GRAVITY FLOW(Check all that appy)' ❑ 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 ALARMS AND 10,CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND(check one) (Check one) ❑ a. 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 ❑ b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c ❑ c. NO AUTO PUMP SHUT OFF NO AUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(30 GPM TEST)NTH FLOW SHUT OFF OR ❑ 11. AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12. ANNUAL INTEGRITY TEST(0 1 GPM) ❑ 12.ANNUAL INTEGRITY TEST(0.1 GPM) SUOTIONIGRAVITY SYSTEM: SUCTIONIGRAVITY SYSTEM'. ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOUS SUMP SENSOR AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check ell that apply) EMERGENCY GENERATORS ONLY(Check atl that apply ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF NAUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF AUDIBLE AND VISUAL VISUALALARMS ALARMS ❑ 15.AUTOMATIC LINE LEAK DETECTOR(3 0 GPM TEST)WTHOUT FLOW SHUT OFF OR ❑ 15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST) RESTRICTION ❑ le.ANNUAL INTEGRITY TEST(0.1 GPM) [118. ANNUAL INTEGRITY TEST(0.1 GPM) C1 17. DAILY VISUAL CHECK FIVRI. LCHECK ' UNI.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILYVISUALCHECK GATE INSTALLED ❑ Z. CONTINUOUS DISPENSER PAN SENSOR-AUDIBLE AND VISUAL ALARMS TRENCH LINER I MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER+AUDIBLE AND VISUAL ALARMS R,. NONE IX.OWNERIOPERATOR SIGNATURE I campy Mat Na information plowde4 herein is true and accurate to Me best of my khbvb09a. SIGNATURE OF OWNERIOPERATOR DATE NAME OF OWNERIOPERATOR(pTITLE OF OWNEPoOPERATOR rvr0 Permit A mvetl Fwiwal use o Peered Expiration Data(For local use ANY) Pemmt Number(Forrocal uss only) pp ( NY) ' CUPAFORM(4199) . . Formerly SWRC8 Form 8