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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 2 -VI.PIPING CONSTRUCTION(Cpeck ap thatapplyj UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE ❑ 1 PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY ❑ 1. PRESSURE ❑ 2. SUCTION ❑ 3. GRAVITY CONSTRUCTIOW ❑ 1. SINGLE WALL ❑ 3. LINED TRENCH ❑99. OTHER ❑ I. SINGLE WALL ❑95. UNKNOWN MANUFACTURER ❑ 2. DOUBLE WALL ❑95. UNKNOWN ❑ 2. DOUBLE WALL ❑99. OTHER MANUFACTURER MANUFACTURER ❑ 1.BARE STEEL ❑ 8. FRP COMPATIBLE WI 100%METHANOL ❑ 1. BARE STEEL ❑ S. FRP COMPATIBLE WI 100%METHANOL MATERIALS AND ❑ 2, STAINLESS STEEL ❑ T GALVANIZED STEEL ❑ 2. STAINLESS STEEL ❑ 7. GALVANIZED STEEL CORROSION PROTECTION ❑ 3. PLASTIC COMPATIBLEWTH CONTENTS 095. UNKNOWN ❑ 3. PLASTIC COMPATIBLE WITH CONTENTS ❑ 8. FLEXIBLE(HOPE) 099. OTHER ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE(HDPE) 099. OTHER ❑ 4. FIBERGLASS ❑ 9. CATHODIC PROTECTION ❑ 5. STEELW/COATING ❑ 9. CATHODIC PROTECTION ❑ 5. STEEL W/COATING ❑95. UNKNOWN 'Al.PIPING LEAK DETECTION(Checkattthat appy) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING SINGLE WALL PIPING PRESSURIZED PIPING(Check as that apply): PRESSURIZED PIPING(Check all that apply): ❑ 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPM TEST WITH AUTO PUMP SHUT OFF FOR ❑ 1. ELECTRONIC LINE 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 02 GPM TEST ❑ 2. MONTHLY 02 GPM TEST ❑ 3. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 3.ANNUAL INTEGRITY TEST to 1 GPM) ❑ 4. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS', CONVENTIONAL SUCTION SYSTEMS(Check all that apply): 5. DAILY VISUAL MONITORING OF PUMPING SYSTEM.TRIENNIAL PIPING INTEGRITY ❑ 5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM TEST to I GPH) ❑ e. TRIENNIAL INTEGRITY TEST(Ill GPM) SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING)'. ❑ 7. SELF MONITORING ❑ 7. SELF MONITORING GRAVITY FLOW'. GRAVITY FLOW(Check an that appy): ❑ 9. BIENNIAL INTEGRITY TEST(0.1 GPM) ❑ B. DAILY VISUAL MONITORING ❑ 9. BIENNIALINTEGRITY TEST(0 1 GPM) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that appy): PRESSURIZED PIPING(Check all that appy) 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL ALARMS AND 10.CONTINUOUS TURBINE SUMP SENSOR WATH AUDIBLE AND VISUAL ALARMS AND(&eck one) (Check ane) ❑ c. 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 ❑ It AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION DISCONNECTION ❑ c. NOAUTO PUMP SHUTOFF ❑ c. NOAUTO PUMP SHUT OFF ❑ 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPM TEST)WITH FLOW SHUT OFF OR ❑ 11.AUTOMATIC LEAK DETECTOR RESTRICTION ❑ 12 ANNUAL INTEGRITY TEST to 1 GPM) ❑ 12. ANNUAL INTEGRITY TEST(0 1 GPM) SUCTIONIGRAVITY SYSTEM: SUCTION/GRAVITY SYSTEM: ❑ 13. CONTINUOUS SUMP SENSOR AUDIBLE AND VISUALALARMS ❑ 13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check ea that appy) EMERGENCY GENERATORS ONLY(Check as that appy] ❑ 14. CONTINUOUS SUMP SENSORVATHOUT AUTO PUMP SHUT OFF+AUDIBLE AND ❑ 14. CONTINUOUS SUMP SENSOR WTHOUT AUTO PUMP SHUT OFF+AUDIBLE AND VISUAL VISUALAIARMS 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 ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 18. ANNUAL INTEGRITY TEST(0.1 GPM) ❑ 17. DMLYVISUALCHECK ❑ 17. DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT ❑ 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE ❑ 4. DAILY VISUAL CHECK DATEINSTALLEO ❑ 2. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS Cl 5. TRENCH LINER I MONITORING ❑ 3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR DISPENSER-AUDIBLE AND VISUAL ALARMS B. NONE UL OWNERIOPERATOR SIGNATURE I certify that Ne inronnabon provided herein is bus and accowta to Na bast of MY IcKW 110 SIGNATURE OF OWNE WOPERATOR DATE NAME OF OWNERIOPERATOR(Pont) TITLE OF OWNER C)PERATOR Pamlit Nnmbef(For local we only) Permit Approved fPo hocal use only) Perms Expiration 0ete(Forlocal use only) CUPAFORM(4199) • • Formerly SVVRCB Farm B